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My patient: Radicular L. Back Pain

My patient “Rad” has been coming to the clinic for about 4 weeks now with complaints of low back pain and radicular symptoms into the right thigh, right medial foot, and slightly into the right calf.

My patient has lordosis of the lumbar spine and significant kyphosis of the thoracic spine. The patient is active and wants to return to activities like swimming, walking long distances, and simply standing for long periods of time without having symptoms in the right leg.

The primary complaint is numbness and tingling in the medial right calf and foot. The patient also has some numbness and tingling into the lateral thigh which occurs less frequently, but can cause the patient discomfort from time to time. All of his symptoms are aggrivated with long periods of standing, walking, and swimming. He does not feel pain, but simply notes a discomfort disscribed as a constant part of his thigh or foot “falling asleep”.

As student physical therapist, it is my challenge to remedy this patients condition to the best of my abilities. This has lead me to find the best evidence for how I can help. You can follow along!

Up until now, I have focused on manual therapy techniques to relieve pain and improve the biomechanics around the joint segments of his L4-5 lumbar segments on the right which show significant muscle guarding and stiffness. At this current clinic, gaining mobility in the spine is encouraged with extension press ups. The patient has seen improvements with the combination of press up extensions and manual therapy.

Breifly looking at some pictures of dermatomal and peripheral nerve patterns, we can take a look at my clinical reasoning to determine that the patients symptoms are not distal to the spinal nerves of the lumbar spine. Or at least, the majority of the symptoms origin from a more proximal location along the nerves exiting the lumbar spine.

Looking at these diagrams, you can observe my reasoning for proximal nerve compression involving spinal nerve roots instead of more distally located compression. Distal compression of the nerve may indeed be present, however, the primary symptoms follow a sensory pattern that indicates possibility of L3, L4 involvement on the right side.

So is there muscular involvement? Myotome testing is negative. However, there is noted weakness of the right gluteus maximus and medius muscles compared to the left side. The innervation for these muscles involves the superior gluteal nerve with spinal innervation involvement of L4,5,S1.

When performing slump tests, streight leg raise with tibial nerve bias, and femoral nerve tension tests, the patient has noted positive symptom aggrivation. The symptoms were especially aggravated in the medial foot with a tibial nerve bias straight leg raise.

So this gives you some idea of the presentation of my patient. I am on a quest to determine if nerve mobilization to nerves containing (L2, L3 due to some discrepancy on the pattern of these nerves in the thigh), L4, L5 nerve roots will improve patient symptoms in the foot and lateral thigh.

I am researching an article: Effectiveness of neural mobilization in patients with spinal radiculopathy: A critical review

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Overview of Lateral Epicondylagia and Lateral Tendinopathy: patient

Treating in clinic on my internship, I have encountered a patient who has lateral elbow pain. This is indicated with tenderness to palpation of the lateral epicondyle, the common extensor tendon, pain with wrist flexion when the elbow is extended. The pain is localized to the ECRL muscle belly. This particular patient also has hypertonic upper trapezius muscles bilaterally, but more so ipsilateral to the arm with lateral elbow pain. Investigating the literature, I found and read 2 articles concerning the dx of lateral elbow pain and considerations in treatment.

“Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All”

- Focused on the importance of individualizing treatment without treating patients in a cookie cutter method. Exercise dosage and manual treatments should be provided based on patient report of symptoms and clinical judgement of the therapist.

- emphasis on determining if the pathology is reactive tendinopathy or degenerative tendinopathy. This will help in determining proper exercise intervention options. Isometric exercises were recommended for patients with more acute symptoms indicating reactive tendinopathy. They should perform exercises within “non-painful” ranges of motion and isometrics. Progression should include increasing weight/force used or the duration of the isometric. Initially, isometrics should begin at around 30 -90 second holds. The wrist should be brought into slight extension (20 -30 deg) during the holds.

- Pain during exercises should not increase above 3/10 or 5 cm on the 10 cm pain scale. This was indicated for when the patients are performing isometric or eccentric exercises.

- There is no conscensis on whether eccentric or concentric exercises are better to progress the patient. However, eccentric exercises are shown to physiologically aid in promoting collagen formation and re-alignment which may be indicated for patients experiencing degenerative tendinopathy.

- motor control should not be neglected as well. Motor control exercises should focus on dissociating digital extension from the wrist extensors. An example exercise was provided indicating that the patient should practice extending the wrist while not extending the metacarpalphalangeal joints. This could be performed with the forearm on a table while extending the wrist while keeping the fingers on the surface of the table.

- Cervical thoracic region should not be neglected. Cervical treatment and postural interventions should accompany treatments of patients who have a positive ULTT of the radial nerve especially. Nerve glides may also be effective. Neck and shoulder pain with individuals with lateral epicondylagia was most commonly seen at C4-7.

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Inadequate?

This is a question that enters my mind frequently. Am I inadequate? There are several experiences and comparisons that make me consider such a question. Looking at others and what they have achieved is a major fuse to these types of thoughts. In my mind, I think to myself, “they are so successful, but here I am feeling like I have never left the launch pad”. I try desperately to find my significance. But sometimes it seems that I run with my mind and simply stand still with my feet. I imagine myself as a great thinker, who can solve problems and who can perform a skill that I am master of...physical therapy. As I list these attributes, I cannot help but cringe a bit. What if I am truly imagining? What if I am truly inadequate? This is such a scary terrible thought to me. It builds a rage in me against others whom I naturally enter competition with or who try to compete with me. Perhaps this is my big brother syndrome kicking in? Maybe I just like to feel like I am the best and I want to be nothing but the best. When I feel like I am not the best or that position is threatened, I become insecure with these feelings of inadequacy. I begin to fear. I begin to fear that I am not really the best, but in fact the worst. I begin to fear that the things I think I know are not really there or simply do not matter.

This sounds very familiar from the bible. But I have to tell you that these are the areas of the bible that I understand the least. Each person runs his or her coarse. Yes...this makes sense, but what about when I get left in the dust. What about when I am nothing and I get to see the people around me soar to stardom. Then...this whole theory seems like a bitter poison to take.

Be happy for them.

Lord... this is something only you can do because I want what they have too badly. I want to feel important so badly it hurts. More than that, I want to be important. I want to mean something to someone. I want to be a master of my skill and know exactly what to do and when to do it. I want to be able to answer a question when the relatives ask and then be able to astound them with how amazing my life is. I want them to think,”wow...he is truly important!”. This is really what goes on in my head. This is really what I think. But here I am...feeling like I should know more. Feeling like I get tongue tied answering the famous question. Feeling like I am inadequate nothing. Then I think...maybe I need to fight harder! Maybe I am not trying hard enough?! Maybe if I only absorb myself fully into my work and school completely I will rise from the books and the work with this feeling of adequacy. Instead, I have found myself waking to people rising above me. I have found myself to still have the same doubts I have always had about my knowledge and what I know. I still ask myself if I am inadequate. And for some reason, I feel more inadequate than ever as I see that despite my great efforts, I still end up in a pile of insecure mess.

So here it is...this is my rage and my thorn and my pain and my discouragement. This is the truth Lord. Help me.

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Darkness is the complacency of light

12/15/16 , Thursday night while clicking off the lights before bed

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This video is interesting and gives, I feel, some unbiased opinions about some evidence that exists concerning a concept of the world that is upheld by words of the Bible.

I am always one to question. I do not like to take words and ideas and rules for granted. The mind with answers creates a world. The mind with questions traipses out into the world to discover and understand it.

I am also slow to explain away evidence existing against biblical concepts. I am not naive. However, I do believe from my observation of educators and some scientists, that the art of the question has become biased to fit a set rectangular stiffened creaking rusty ideas. Truly, we should develop our wisdom and understanding from the past. But even these ideas and discoveries were developed by individuals who searched to solve a problem or who simply challenged the paradigm of complacency in the world of that time.

So this is neither proclamation nor resolution towards a belief. Rather this is recognition of unanswered questions with reasonable grounds to challenge the rigid ideas that currently shape scientific opinions. This is also an outcry to the curious, the innovative, the idealists, and the non complaints of our world. For surely, these will make the discoveries that mystify and astound and shape a new and better world.

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The New Life

Ah so here I am at the new life! For the past 3 years I have been infatuated with a goal. Now I have tripped upon a new life. I feel myself adjusting slowly to the idea of being finished with the great task. Now I can feel myself searching myself for what is in me. I am looking for what I can give. I am looking for the paths. Come celebrate what is and what is to come! I am somber this morning with the gravity of the search. But here is what I know. I know that I have passions. I have a passion for music. I have a passion for creativity. I have a passion for sports and teaching sports. I have a passion for giving. I certainly have a passion for physical therapy. However, I am beginning to look for the my new direction. I understand for once that I am beyond my parent’s direction. I am truly my own. This gives me butterflies and also is a powerful reminder of new life! New life!

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The Edge of Beginning

Well...I am finished. Finished is such a complete word. Complete!? I am about as complete as a graduate embarking on a new career. I am about as complete as the end of a sunrise. I have learned the alphabet, and now I am going to write words. Complete?! Beginnings are such a strange place to be. There are so many emotions filtering through my head. I am questioning my abilities, but I also trust my abilities to take the next step. The Lord is with me. I feel very much like I did before a big soccer match. I had practiced and performed drills to work on my weaknesses. Before the match I see the other team, I am excited and I am expectant of the outcomes of my training. I know that at the end of this game I would again begin to practice what I was not perfect at in the game. I like comparing life to moments in the past. I like comparing complicated feelings to simple feelings in the past. It helps me understand what I am facing. It helps me break down my emotions and make sense of the world. It is Salubrious for my mind.

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Here I am

I sit here amazed, inspired, tired. The 1st battle was fought the day before yesterday. I met with the intrepid forces of a test. There is no way I can glory in myself. I was more afraid checking the results of that test than I have ever been. I do not pretend to be beyond powerful... because I know it was your hand that guided me. It is strange how in the beginning you seek the lord for help and after the victory, you deceive yourself with the false claim that you and your powers overcame the odds. The argument: I studied, I took the test! Did he truly guide my answers? 

I laugh at myself for thinking such thoughts. What a disgrace my natural mind is. Praying the night before that exam I know that I was carried! Yesterday as I spoke with a therapist friend, I was overcome with an excitement of what the Lord can do! 

Lord, thank you! Thank you for your presence and your hand before me! Thank you for providing a way! Thank you for being with me! I am elated at the outcome of this test! At the same time, I am filled with a powerful sense that you have empowered me beyond the outcomes of a test!

In the next week, another test of my knowledge will occur. It may be the greatest barrier I face! Again, I face a battle! I dive into the abyss, but I know that you are with me!

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I am nervous, but I trust You

Dear Lord,

I am scared, but I trust you. I do not know the outcome of tomorrow, but I trust you to take me where you need me to be. I trust that you will make a way despite the screaming emotions and fears and anxieties I have in my head. I fear that I will be inferior and my mind will be absent of knowledge for 4 hours of time. I don’t know what to say to you. I trust that you have showed me how to implant knowledge into my head, but I know that life is not perfect. I know that I must rest in you even when circumstances are not ideal to the plan that I have construed in my head. However, I know and have experienced how you carry me through the moments when I am feeling inferior and distraught. I have seen you do things in me that I could never achieve. I have seen you bring me through difficulties that I had not foreseen. I have seen you provide for me when my own means were used up. I have seen you infiltrate my heart with peace even in times when I “knew” that I should be scared. YOU are my god. You are my meaning for this school. You are the reason I am here. I want the circumstances to be ok more than anything, but I realize that my purpose is not defined by my circumstances, nor my abilities, nor my outcome tomorrow, but I am defined by your hand before me. I am defined by your presence in me. I am defined by your anointment as a king in your kingdom. I am not defined by the world, or the powers of the world...I am carried by the King of Kings and Lord of Lords. Lord, I do not pretend to be ok...I am not...I am scared...but Lord... You have promised that you are with me in these times.

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The Big Test

I am scared! Have you ever had this feeling like your mind is in a whirl wind? Have you ever had the feeling that you simply cannot control what happens? That is where I am now. I feel like no matter what I do, I am not going to be able to change what the outcome of my test will be. This sounds pessimistic and frankly unsanitary to my academic side of my mind. But I feel as though I am in this habbit of settling because I am tired.

No!

What do I need to do?

I am reviewing: Yes

I have to review peds, wound care, and the rest of musculo!

But the thing I think will help me the most is application. Some type of application of the material. I dont do well with just reading through things and frankly, that is not a real world scenario anyways. I can memorize, but when I get in this tired state, it does not do my mind any good to sit and try to memorize. I HAVE TO START APPLICATION OF THE MATERIAL! This is not for me or for them or for teachers...this is for patients.... since that is the real test. The test will be about applying the information. That is why it will by hard. So why not practice it that way? Do what you know in your heart!

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The Strange Days

Every once in a while, there is a strange day. As strange days go, I doubt there is exactly a specific definition of this type of day. However, one particular day can feel strange or disoriented or uncomfortable for a number of reasons. Today, I had a strange day. I woke up late and had to rush to class. Embarrassed, I entered the classroom 2 min late with a bed head and scroungy clothes. I felt like a failure. I continued the day and found that a few people obviously have negative feelings about me. Maybe this is pure speculation, but I got that feel. I was tired all day. I could not seem to get beyond a fog in my head. Now I am trying to study. I do not feel like studying with this weird feeling looming over me.

Still, there is one thing that does not digress into the world of strange. You Lord are stable. You lord are sure. I am disabled in my fluctuating emotions, but you hold me tight and comfort me. Let me not forget your purpose in me. Let me not forget your promise. Let me not forget that you brought me to this place. Lord put curiosity in me so that I can study. Show me how to overcome this mountain of material I need to engulf. Rest my spirit and sooth my soul. Fill me with your confidence and strength.

In the midst of the strange day, you are my God.

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Say Hello

Always say hello! Wave! Shout! Whisper! Gesture! Smile! Do something! But please...for the love of humanity, and goodness, and hospitality....Say hello!

Hello is not an awkward thing to do. There is nothing hard about it. Hello is something people do to show acknowledgment of other humans.

Saying hello makes the other person feel accepted, acknowledged!

Saying hello opens up your own emotional and social channels!

Saying hello helps you be confident in yourself!

Saying hello sparks friendships!

Saying hello makes you approachable!

Saying hello describes a positive vibe to the atmosphere of whatever environment you are in. 

Saying hello is a gift to another person and to your self. Time is taken and only a bit of effort, but the action creates a divergent chain of events!

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Wish

Once there was a person who briefly touched my heart. Perhaps I will be lucky enough to find just one more person like that. 

There is always one person who frames the thoughts and feelings you have always considered for a special person. Now I am waiting for perhaps the 2nd of a life time. The first was not available for me. But maybe...a second will arrive. A second chance for romance.

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Pondering

Just felt a bit of pain. Its not somatic and not referred. Its inner being spirit pain.

I have been ignorant of what the Lord is doing. I have become distracted by every shiny obstacle. My priorities and thoughts have not been sound and solid.

So Lord...just sitting here...stopping my mind...stopping the chaos...

Ground me in you. Fill me with your presence. Without getting too super spiritual... :)

I am just opening up to be aware of you. I forgot that you are really why I am here in the first place. Once again I realize and remember...

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The Balance! The tight rope! Life!

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Just a quick reminder to myself and all other guys and gals...dont forget...dont forget that you can keep your standards high...dont forget that love is something that is powerful. Don’t settle!

Find the person that makes your heart flutter. Find the person that you just connect with!

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Clinical Reasoning for Christians

So lately, I have been bombarded with some questions from a few christian friends concerning deception in the church. This is a touchy subject. Highly touchy to others. Disgraceful to some. Dumb to others.

There is a conflict between ideas about feelings. There is conflict about shaking. There is conflict about weird stuff going on in some churches.

So where does that leave us?

In Physical Therapy School, I have learned that independent thinking with objective data as a resource is critical to remain safe with patients and provide the most effective care. Christians need to search in themselves and discover the “clinical reasoning of a Jesus follower”.

The Lord spoke about this saying that He would provide His spirit within us for discernment regarding things of the Spirit.

I have found that many people tend to think that this is some sort of ewwy goey idea or that it is by determination directly from exact words of the scriptures or certainly, there are always some who say that this does not exist at all.

Here is what I have found in my observation of people in churches of ALL denomenations, sects, and ideals of christian origin:

1) PEOPLE ARE WEIRD 

- So here is the deal yall. No matter where I go or what type of church I go to, there is always a group of weird people. Face it. It is life. Everywhere you go there is an influence of human nature and mental catastrophe. Yeah, sometimes it is the guy yelling constantly in church. Sometimes it is the woman who feels she needs to pray a certain way every time. Sometimes it is the man that has to add that extra extended “tuh” at the end of every word when he is doing something spiritual. If you don’t think that there are some weird people out there... just go to Walmart and people watch for an hour...

2) PEOPLE MAKE MISTAKES

- I don’t care who it is, how famous, how nice, how cool, how spiritual, how nice, how family oriented, how spiritually sound...people are humans that were saved for a reason. But here is the catch...people hate a hypocrite more than they hate a sinner. People become surprised when an great person or role model comes to eye level because they messed up. Some seem to go from greatness to hell honestly, relative to the observer’s position. Why this is still a surprise, I will never know, but people get very shaken when paster bob does something that is evil. But old Jim in the back row, his evil... well...they pray for him and ask for his redemption. Bob gets roasted. Jim gets all the protective advice. Paster Bob gets ooos and ahhhs and bows until he turns into the “devil” to everyone.

3) PEOPLE DO NOT QUESTION OR TEST

- Most of all, people like to follow the leader. Just look at the culture yall. Whether you are apart of it a lot or a little...it effects you. Now do you think that a church or an idea is completely removed from this same concept. Do you not think that culture enters your sanctuary? Do you not think that selfishness stays at the door?

SO HERE WE ARE: SEEMINGLY ALONE:

But maybe this is something to think about. The Lord gave YOU his spirit for discernment. The Lord gave YOU his gifts. The Lord made YOU!

So I don’t really know what to tell you about all the controversy. I don’t plan to tell you how you should believe. You are in a relationship with the Lord...ask Him about it...

But consider this when your mind starts to run: remember that you may have to put up with some people that are weird just like you have to at the office. You ain’t gonna change that co-worker any time soon... but you understand them and move on.

Remember that all people are having problems. It doesn’t make the problems right by saying that, but just remember that it is your relationship with the Lord, and not some earthly spokes person. Take their advice...test it...ask the Lord about it...discern in your spirit and with the Bible...

Remember to keep an open mind. Im not saying to go new age or anything, I am saying to THINK! I am saying to question EVERYTHING. Question their beliefs! Question yours! Question yours! Question yours!

If you don’t think you should question if you might be wrong... consider this...

When was the last time you made a bad decision?

When was the last time you did not make 100% on an exam?

When was the last time you STOPPED LEARNING?

HAVE YOU EVER STOPPED LEARNING?

If you honestly considered all of these questions, you will know that YOU...even YOU..can be wrong...but certainly YOU can be right too!

So go with Sound Mind!...into the churches and into the christian concerts...learn to use your “clinical christian reasoning”