Prognostic Value of Within Session Changes – Systematic Review

[Aaron Hartstein]

Hi everyone,
Happy holidays. This is a new article in press that looks at the prognostic capability of within or between session improvements. Considering that we often assess for these changes and frequently use them to educate patients and leverage patient-therapist rapport/trust/compliance, I was a little disheartened to see read their conclusions. What are your thoughts on these findings and does this change your practice or reassessment post intervention?
Aaron

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[awilson12]

I think that with such a narrow population (majority looking at McKenzie and low back pain) it is hard to generalize the poor quality, limited evidence that this systematic review based their conclusions on. I still think that symptom modification serves as a good educational tool and guide for areas of treatment, but hanging your hat on that shouldn’t be and can’t be the end of what we do. I feel like it is an oversimplification to base treatment solely off of symptom alleviation without regard for other objective and subjective measures that are also helping us to gauge effectiveness.

I will admit, easier said than done, though, because so many people just want pain reduction and this can be a low hanging fruit to assess and re-assess. I agree that there likely needs to be more evidence on this and we probably aren’t as good as we think we are. Just goes to show the importance of 1) specificity in treatment, 2) ensuring we are making things functional to help with long-term carryover, and 3) educating on improvements in other outcomes besides subjective reports of pain and disability.

For me this is a good reminder to be better about choosing what I am using for test-treat-reassess and education on this.

[helenrshep]

Interesting article… As much as we as clinicians discuss the topic of within and between session changes it is interesting that the authors could only find 13 studies that met inclusion/exclusion criteria. Like most things with PT, I think this may a hard area to research appropriately which may have contributed to the lack of significant findings.

I think within/between session changes are good for rapport and open a door for education, but in terms of using those changes to determine prognosis, I think like everything else it should be a cluster. Those changes are just one of many variables we should be considering when determining prognosis. Many of those variables may go hand in hand, like the presence of yellow flags that would lead to a poorer prognosis may also cause difficulty in making within session changes.

[Steven Lagasse]

Based on this study, I am uncertain I would forego the test-retest model. Coming into residency, the utilization of a test-retest model was somewhat new to me. My initial approach was to identify a problem list and treat those impairments biomechanically. Although fond of this approach, I was commonly left feeling unsure if my interventions were meaningful. The incorporation of a test-retest model has served me well in assuring that my biomechanical treatments were meaningful to both me and the patient.

Removing this model from my practice would leave me with the question, “And replace it with what?” Ultimately, I feel this act would do more harm than good. Anytime someone removes a belief system, ideology, or this case a treatment model, they are left with less than they once had. The scaffolding that had once served them has been torn down- something inevitably needs to fill that void.

Although this article does a good job of pointing out that there may be holes in the test-retest model, I’m sure this would be true with nearly all models. Our due diligence comes in the form of being cognizant that our approaches are imperfect. It is up to the clinician to remain eclectic, adjusting and adapting as needed, especially when an approach or model is no longer serving us and/or the patient.

[Taylor Blattenberger]

Helen,

I agree, this is a difficult area to research. The broad topic of “within session changes” can take a lot of forms which this article highlighted well. Are we looking for more range? More strength? Less pain? Better movement? To lump these all together may not be an effective means to assess the concept as a whole.

To Anna’s point we absolutely need to tailor our treatment sessions to promote carryover and goal directed outcomes. In-session pain relief is not enough for most patients to reach their functional goals, yet that is typically what I’m after in an assess-reassess scenario.

I’m curious, what are you all typically assessing-reassessing if/when you look for in session changes?

[awilson12]

Taylor-
I think that it is patient dependent for my assessment/reassessment based on goals of the treatment. For example, if I am doing a manual technique for range of motion improvements then I will look at just that; compared to a technique for pain alleviation then I might assess range of motion still but look for any changes in quality of movement and pain reproduction.

Where I struggle more is identifying more functional assessments to look at pre and post treatment that I would expect to improve with whatever manual therapy technique I am doing. I think that being better about this can help with patient buy-in and also reassessing subjective asterisks as well as objective.
Anyone else in this boat and have helpful tips on how you have worked to improve this?

[helenrshep]

I’ve been thinking about this article so much this week! I tend to do a lot of assess/re-assess to determine effectiveness of my technique and really look for within session changes to guide my treatment.

For example – anterior hip pain – positive FADIR, FABER, and psoas and pain with active hip flexion (just to be brief). I had him run then did soft tissue to psoas and then had him run again. No change. Then I tried mobilizing his hip joint and had him run again. No change. Then I had him do lateral band steps and side planks to better activate glute med and had him run again. It was better. So then I concluded that getting his glutes on would make the most difference, so that’s what I gave him for home. Maybe not a super fantastic approach, and you could argue it might have been the compound effect or that I did too much within the one treatment session and if he came back worse we wouldn’t know why… but I think it helps guide my treatment and gives me good information. I’ve seen this strategy work well and my mentor really emphasizes it as well. Thoughts??

[pbarrettcoleman]

I practice this way all the time. Stealing Aaron’s pie analogy, every patient has multiple impairments, we just don’t know how big each slice of the pie is. I would imagine the only way to figure that out is doing an assess-treat-reassess as you begin to funnel through the Objective * list using clinical findings to inform your treatment.

With your particular treatment Helen, you used running as an objective * and did STM, Joint mobilization, and motor control to find which intervention fit your patient. I approach problems like this all the time until we can do more pattern recognition via building up a rolodex through more patient contact.

The only thing (which you may have done but didn’t list due to brevity) was finding impairments that matched those interventions. So if FABER, FADIR were positive, looking for side to side differences in joint mobility to have more evidence to do a joint mobilization. Same for soft tissue (difference in side to side upon palpation or + MLT). I find having that interim objective * helps reason through impairment list and avoids the shotgun approach… which I admittedly have done at times.

[lacarroll]

I agree with everybody that this is a hard topic to research effectively. Barrett and Helen, this is something I’ve really been focusing more on this last week too. I’ve been trying to be more consistent at assessing-reassessing after specific interventions, rather than after multiple techniques so that I can assess my ability to achieve the results I want. I feel like I’m in the same position as Anna where I feel like I’m not always sure what functional movements are appropriate to assess-reassess, particularly when the patient has multiple areas of impairments. I also feel like sometimes it takes so much time to assess-treat-reassess when there are multiple areas of impairments. How do you guys manage that with the rest of your treatment without spending all day with your patient?

[pbarrettcoleman]

I tend to take three or four things from multiple systems (function, active, passive, joint mobilization, neuro, MMT, special test, etc). That way I can capture the array of things our techniques can change. So using Helen’s patient as an example, I might have that person run in the clinic, FABER, AROM Hip Flexion, TTP to psoas and then do my treatment and check those four things for changes. That way I can see what gets better or worse and go on to the next thing so I know how big each slice of the “pie” is with each patient (for instance, if it’s more about soft-tissue restriction, then you will see more improvement with your objective *s with those interventions vs. joint mobilizations vs. motor control).

[awilson12]

Barrett- Good point on being more methodical with choosing things from multiple systems and then assessing tolerance to various treatments to determine effect across multiple asterisks. I tend to just target one or two specific asterisks at a time that I am trying to improve/think will improve and neglect the other important ones during that specific intervention. Expanding this process to be more encompassing to determine various contributions from different symptoms is something that is worthwhile to adopt/change.

Lauren- I think that test-treat-reassess can be overwhelming in a time crunch (or on a Friday afternoon when your brain is fried), but I feel like on the back end it can be so much more beneficial and likely get the patient better quicker when we are taking the extra time to be specific and methodical. Also, like what Barrett discussed, being intentional about what we are assessing (and not just looking at every single thing every time) saves time as well. Easier said than done but good to consider and challenge current practice patterns!

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