If you are familiar with the work of Diane Lee, you may have noticed the term “driver” used throughout descriptions of patient assessment techniques. One definition of “driver” is “a factor that causes a particular phenomenon to happen or develop.” When it comes to a patient’s pelvic dysfunction, we know that there may be a dramatic number of factors driving the symptom, so what is the value of trying to determine the level of significance of various factors?
Let’s imagine that we meet a female patient who presents with pelvic pain, urinary incontinence, and difficulty holding back gas. In addition to providing a thorough subjective interview, screening for underlying medical conditions requiring attention, examining her neuromusculoskeletal system, and learning more about her daily habits, we need to figure out the best place to start with her care. What if, even though this particular patient has only experienced one major episode of leakage (after which all other symptoms started) you complete the exam to find that she is holding her pelvic muscles tense continuously? Perhaps you share this observation with the patient, only to hear her say that she is “so afraid of leaking again that she keeps her muscles tight to prevent it.” This type of rehabilitation sleuthing can help us get to the heart of the matter with our patients, regardless of the presenting complaints. For example, if we can educate this patient about the potential negative consequences of her fear of having another embarrassing episode (fear leads to muscle guarding which leads to pelvic pain and potentially dysfunctional voiding) then her thoughts can positively contribute to the other therapeutic recommendations we make.
Other examples may include meeting a patient with pelvic dysfunction whose true “driver” is a kyphotic thoracic spine that compresses the abdominal organs, or a habit of wearing pants with a waistband so tight that bowel function is compromised (true story), foot pain that creates increased loading on the now painful side of the pelvis, or even emotions and thoughts such as fear and shame. I’m sure you can think of many other examples based on your own clinical experience. If you are a newer therapist, or perhaps wish to work through further examples of not only how to evaluate but to treat for finding the primary contributors to a patient’s dysfunction, check out Pelvic Rehabilitation Institute faculty member Elizabeth Hampton’s continuing education course that focuses on this Finding the Driver in Pelvic Pain.
Today we get to hear from Mitch Owens, MsPT, COMT who is the author and instructor of "Neck Pain, Headaches, Dizziness, and Vertigo: Integrating Vestibular and Orthopedic Treatment". Join Mitch in Rockville, MD on November 14-15 in order to learn more about treating patients with head trauma.
Following a whiplash injury, concussion or vestibulopathy patients will complain of the same cluster of symptoms: neck pain, dizziness, and headache. In order to properly treat patients complaining of these symptoms a clinician must first be able to determine the source and understand the physiology at work to reason out the best plan of care.
Treating individuals for dizziness, neck pain and headaches requires a refined understanding of the systems involved, the clinical tests that can be used to differentiate symptom generation and then finally which evidence based interventions should be deployed.
A patient who presents with a complaint of dizziness or vertigo following a trauma to the head or neck will challenge the examination skills of even the best practitioners. The list of differential diagnosis includes a number of conditions that could prove to be quite threatening to the patient with or without intervention. These conditions include: vertebral basilar insufficiency, cervical fracture, dislocation or instability, stroke, traumatic brain injury, concussion, and peripheral vestibulopathy to name a few. The ability to clinically reason and properly assess these individuals is crucial to the effective management of any orthopedic or neurologic case load.
Clinicians treating either population need skill sets that bridge the orthopedic and neurologic expertise gap that often exist if clinicians. The need to close this gap is highlighted the following facts:
- 15-20% of Benign Paroxysmal Positional Vertigo is caused by trauma (Gordon, Carlos et al. 2004).
- 19% of cases of whiplash demonstrated vestibulopathy with videonystagmography (VNG) testing within 15 days of their accident (Nacci, A. et al 2011).
- 60% of cases of whiplash with head trauma demonstrated vestibulopathy (Nacci, A. et al. 2011).
- Dizziness is reported 20-58% of whiplash patients (Wrisley DM et al. 2000).
- Between 40%-70% of individuals with persistent whiplash associated disorders complain of dizziness (Treleaven, Julia et al. 2003).
- The incidence of cervicogenic dizziness has been reported to be 7.5% of all dizziness (Ardic FN, et al. 2006)
Recent evidence has shown that sensory dysfunction is as much a part of dizziness as it is a component of chronic neck pain (Treleaven, Julia et al. 2003).
Interventions directed at training cervical proprioception have been show to significantly reduce pain and has improved function in patients with chronic neck pain (Revel, Michel, et al 1994). Manual therapy techniques directed at the upper cervical spine have also been shown to effectively treat dizziness in randomized control trials (Reid, Susan A., et al. 2013).
Thus we are learning the ability to effectively measure and treat neurologic dysfunction is an important part of address cervical spine issues. It is equally true that being able to assess and treat cervical spine dysfunction is an important part of treating patients who complain of dizziness.
Enhancing your neurologic and orthopedic skill set is clearly useful for any clinician and will help improve your outcomes across all patient populations. Continued training in these areas will expand what patients you can see, add to your clinical tool belt, and improve your confidence within your current caseload.
Ardic FN, Topuz B, Kara CO. Impact of multiple etiology on dizziness handicap. Otol Neurotol. 2006;27:676 – 680.
Gordon, Carlos R., et al. "Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form?." Archives of Neurology 61.10 (2004): 1590-1593.
Nacci, A., et al. "Vestibular and stabilometric findings in whiplash injury and minor head trauma." Acta Otorhinolaryngologica Italica 31.6 (2011): 378.
Reid, Susan A., et al. "Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial." Physical therapy (2013).
Revel, Michel, et al. "Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study." Archives of physical medicine and rehabilitation 75.8 (1994): 895-899.
Treleaven, Julia, Gwendolen Jull, and Michele Sterling. "Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error." Journal of Rehabilitation Medicine 35.1 (2003): 36-43.
Wrisley DM, Sparto PJ, Whitney SL, Furman JM: Cervicogenic dizziness: a review of diagnosis and treatment. Journal of Orthopaedic & Sports Physical Therapy 2000, 30(12):755-766.
Today we get the opportunity to hear from Herman & Wallace faculty member Elizabeth Hampton PT, WCS, BCIA-PMB! Elizabeth has been kind enough to offer her insights about the diagnosis of pelvic rehabilitation patients. Join Elizabeth at Finding the Driver in Pelvic Pain this November in Houston, TX in order to learn evaluation tools for complex pelvic pain clients!
Having taught for Herman and Wallace since 2006, I have a few observations that have been consistent over the years. Clinicians want their clients to get better, so much so that they are ready to jump in to treatment before having a solid problem list and validated findings. I can understand this: after a 3 day course we have clients Monday morning at 8 a.m. who have been waiting for us to take this course so we can get them better! We had better be smart ASAP! But what do we do when we are treating symptoms rather than understanding the primary, secondary and tertiary factors in their condition?
Finding the Driver in Pelvic Pain is a course that is a foundational first step in screening the pelvic pain client. It is a great place to start. I developed the course because there was no evidence based comprehensive factors that had been established as fundamentals for screening a pelvic pain client.
The other thing I have learned after teaching Pelvic Floor Function, Dysfunction, & Treatment – Level 2B for 9 years is that the majority of clinicians who take this intermediate level course cannot perform a precise vulvar and intrapelvic muscle mapping assessment. Close your eyes and pretend you are mapping a client’s left iliococcygeus: can you place your finger in the proper orientation and know 100% you would be palpating it? Indeed, this takes training and repetition. Internal pelvic floor muscle mapping is a key part of the Finding the Driver screening system.
What do you do when you have a pelvic pain client on your schedule and a 45-60 minute slot? How do you screen findings and get the plan of care within such a short period of time? Finding the Driver is a comprehensive pelvic floor and musculoskeletal screening to rule in or rule out drivers of the pain from all sources including spine, pelvic ring, neural entrapment, intra-articular hip, load transfer, biomechanics and motor control. There is a clear flow to the screening process and an emphasis on how to organize that information, as we know with pelvic pain, it is the copious amount of information that is the challenge. We have two case studies with either participants or clients of a local Physical Therapist who come in and we go through the entire screen, prioritize treatment and provide that treatment during the course. The participants walk away with clear clinical reasoning for their treatment and prioritization of treatment as primary, secondary, and so on. The goal of the course is to help the clinician sort through the extraordinary amount of information we gather on our pelvic pain client and organize it in a way that we can explain to the client as well as create our plan of care. Treatment is not linear, as we are frequently treating many aspects at the same time. However being able to organize the information is key in designing that plan of care. For example, with a prone knee bend that reproduces labial pain, we find that the genitofemoral nerve is causing referred pain. However that referral may be due to constipation, irritable bowel, inguinal entrapment due to hernia surgery, intra-abdominal adhesions due to endometriosis, osteitis pubis or facilitated segment at the upper lumbar spine. How do we tease that out? How do you sequence nerve glide, visceral work, soft tissue mobilization, joint mobilization and dietary components for colonic motility? The treatment with all of those components are very different indeed. Finding the Driver is a hands on course with systematic screening tools and, with case studies, we go through treatments appropriate to that client. The focus is on what we, as physical therapists, can do to understand the drivers.
At the last Finding the Driver course in Milwaukee, WI, we had two case studies in pelvic pain. One client reported chronic psoas and adductor tightness with deep left sided pelvic pain. As a professional aerialist, she was extraordinarily flexible and demonstrated positions of tightness that concerned her, which included lateral splits with her hips in slight horizontal abduction and extension (yes, yikes!) When she reported that her adductor felt tight in this position, I explained it was because it was trying to keep her leg attached to her body! She was 9/9 on the Beighton scale and had severe multidirectional instability in her hips, impaired load transfer through her pelvis, respiratory dysfunction with efforts at pelvic floor and transverse abdominis contraction, as well as repeated choice of activities that were profoundly provoking. Interestingly, she was better at load transfer during handstands (bilateral or unilateral) vs. in standing and we discussed her course of treatment addressing the primary, secondary and tertiary aspects of her condition. Another client had severe labial pain, and despite multiple abdominal and intravaginal surgeries, her symptom onset was 4 months prior. She certainly had visceral, postural, joint restrictions, movement dysfunction and many other factors. But her primary driver was a labral tear in her hip and she needed surgery. After surgery, her pain was 100% resolved and in her post op rehab, the other factors could be addressed.
It is safe to say that it can be difficult to perform a comprehensive screen in 45-60 minutes on ALL clients. We all know that many of our clients need to tell their story and because of fear or previous negative history, we may choose as clinicians how to spend that session to best honor the needs of the client. That being said, Finding the Driver is a course which provides a solid start in differential diagnosis so you can drill down into more specifics on subsequent visits.