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Nice work, everyone. Perhaps it is the content of my recent qualitative research and multicultural management coursework in my program, but I will add another perspective here, just for the sake of discussion. In working with individuals from this culture, it is important to understand their worldview and lived experience. Depending on her level of acculturation to Western beliefs and values, there may be conflicts related to traditional gender roles in her culture versus our more flexible and current Western views. Maybe she indicated that her symptoms were still there and requested the imaging herself, in attempt to expedite her recovery (from her perspective). Another factor to consider is the traditional view of fatalism (misfortune being inevitable and being resigned to it) in this culture. She may be happy going along passively with the NPs suggestion as a result of this perspective. From a holistic point of view, questioning her beliefs of about spirituality/religion may reveal something else to discuss or, better yet, leverage into your treatment approach. I know this is all a bit “touchy feely” in nature, but I thought it was interesting to assume that it was all driven by the NP and her decision making, when there could be another factor in the equation here. Just a thought.
Hi everyone,
Nice discussion here. I appreciate all of your comments. I found the article useful in that it rearranged some prior thoughts of mine about the utility of a bone scan (being more Sn than Sp, in this review). Regarding the use of US by the PT in this case – while we certainly have the ability to use this tool and informally assess for this type of a lesion, creating a medical diagnosis or labeling the impairment as a stress fracture would be outside of our scope (and in theory, practicing medicine without a license to do so). Like anything else, it depends on the situation and the formality. For instance, we have one at school and often look at things informally, which could influence education, management, or when to refer out. But, this may not be the case in the clinic or if there was special interest from other stakeholders (consider a POPTS for instance, who has their own MRI machine). I found it interesting that Cameron was the only one to discuss the potential for an orthotic. I think conducting a non weight-bearing biomechanical exam on this patient would be highly relevant and a temporary orthotic or a modification to an old orthotic may be a way to provide some additional unloading in the short-term.Hi Tyler.
When reading this, I thought you were going to comment about the chronicity and/or sensitization of these patients. If there is an issue of sensitization here (which I realize might not be the case at all), than consider that sometimes additional areas will become symptomatic as well and that your treatment might have to include elements of TNE/PNE in addition to treating the primary or source of initial symptoms (top down and bottom up treatment, according to the TNE/PNE folks). However, if this is not the case (and it sounds like it may not be), I agree that focusing on the worst area and impairments that we know connect the two regions (thoracic spine) may be more beneficial than chasing two separate pains in one session, manually. Your exercise selection, on the other hand, can be the link to treating both simultaneously. If you were to test their extensor endurance (like Rusty Smith suggests), you might very well provoke both symptoms, especially considering their is an endurance component to their complaints. If this is true, than your exercises could focus on the deep longitudinal sling and incorporate both areas at the same time. This way, your manual therapy techniques may only need to address the hypomobilities in the thoracic spine and ribcage while your more specific ther ex, considering the type of contraction they need (isometric and against gravity), treats the motor control component of the other areas. Just my 2-cents.
AaronHere you go.
AaronHi Justin,
TOS can be a frustrating thing to work with, especially considering the lack of great evidence to guide our assessment and treatment, as well as the poor special tests we have to identify these issues. We will talk about this some in Weekend 3, but the majority of these cases are considered disputed neurogenic TOS (90+%) and have (-) diagnostic testing. True vascular, arterial, or neurogenic, only accounts for < 10% of these cases – and they will have (+) testing/imaging. Successful treatment of these folks is really an exercise in anatomy and understanding where the inferior portion the plexus can be restricted, what adjacent structures could promote this dysfunction (thoracic spine, CT junction, 1st/2nd rib, posterior capsule of shoulder, pec, AC/SC joint, etc), and having procedures to assess this – ULPT 3, for example. I would recommend approaching this the same as you approach other patients – identify objective impairments, have solid objective *, treat an area, and reassess that area, as well as others to determine what type of carry over you have, if any. Here is a nice series that Phil Sizer put out a couple of years about that has a helpful table about how to structure treatment pending their response to our objective testing. Hope this helps.
AaronHey Eric – I think we should contact Gail J. and see why VOMPTI was not acknowledged for the clinical reasoning form. Royalties?
Really great thread – one of my favorites so far. I think it is important to recognize another factor that may have propelled this type of thinking. There was a time where manual therapy did not have the strongest outcomes in our literature and as a result, insurance companies were questioning payment for certain procedures. We now know that much of this was due to poorly designed studies assuming that all back or neck pain was created equally. Enter the classification system, which was an initial attempt to show that when applied appropriately, to the appropriate subgroup, our techniques actually do work. The problem, as I am sure you are all aware, are the extremist views that our CPRs are gospel and replace our clinical reasoning, and even more dangerous, perhaps, are studies indicating prescriptive types of treatments (mobilizing L4 for all back pain can have the same results as specific assessment and techniques, for example). I think it is imperative that we know where we came from historically as a profession, what lead to some of the initial designs of these studies (to get us paid, to get us DPT and MSK expert status, etc) and not swing towards the extremists views that may water down what it is that we do that is so special – care for individual patients in a specific and not prescriptive manner.
I am really glad to see that this article caught the attention of the residents. I think this falls well in line with what we discussed for the lumbar spine and its continual evolution with regards to subgrouping over the last 10 years. It does seem, in general, that evidence regarding classification for the cervical spine has lagged behind the lumbar spine somewhat. There are some reasons for this, but why do you guys think this is so? Do you think that this classification captures those folks with chronic non specific neck pain well enough?
As for the slump test, and especially the long-sit slump test for cervical spine dysfunction – this is commonly discussed with cervicogenic headache presentations.
When I read this article and looked at the thread I could not help but think about the muscular slings that Rusty Smith talked about last year and how we should incorporate this into our assessment and functional treatment. Continuing with Myra’s theme, developmentally this certainly makes sense. I am wondering how many of you residents take into account these type of muscular activation patterns and utilize them in treatment – for example, using the upper quarter patterning with lower quarter symptoms and vice versa. Thoughts?
While I agree that true fear-avoidant dominant behavior is not seen that commonly in a typical OP practice, I think we commonly see altered behaviors and movement patterns, many of which persist unbeknownst to the patient. O’Sullivan made a distinction between adaptive and maladaptive behaviors. No different than using a crutch or a brace for a period of time, limping or having a lumbar shift may be necessary during the acute phase of an injury. However, this behavior and pattern may become maladaptive if maintained over a period of time. Identifying and discussing these patterns with patients can help with the overall education and alliance of your sessions. Pointing out to a patient that they sit with less weight through one side of their pelvis, or asymmetrical weight acceptance with transfer, etc., can be huge talking points and asking “why do you do that” will open a dialogue that often will assist your care. While these outcome measures give some meat to what we do, do not forget to assess and address the physical situation you observe as well.
#MakeOrthopedicsGreatAgainI would like hear what your strategies are for educating patients about this and what you feel has been successful – does the same strategy work for all? There are posters and visuals available (Victim of Medical Imaging Terminology – VOMIT) for example. I made a poster for our clinic but have yet to use it, etc. Obviously all individuals are different and have different beliefs, so what other tools have you used or seen used to push your point?
As much as I would like to think that a T4 manip would clear this up, I can not in good faith make my fingers type that. I saw a patient very similar to this when covering for Kyle a couple of weeks ago who had loss of achilles reflex, inability to rise on his toes in weight-bearing, and had not responded to 4 days of a dose-pack. The strong neuro findings which did not respond to treatment were concerning and he eventually had imaging and a 1.4cm hernitation on his S1 root which he had decompressed recently. I would be most concerned with your patients neuro findings and inability to generate a heel raise. O’Sullivan talked about the propensity for larger herniations to heel and this is true for others I have seen (our director’s husband had a 9mm herniation and he responded very well to PT last year and avoided any non-conservative management. However, while he had a very (+) MRI, his neuro status was not as involved as Kyle’s patient or yours.
He obviously has strong neurodynamic findings – SLR, Slump, what sounds like passive neck flexion, etc. Did you do long-sit slump on him since you were interested in his sympathetic chain and T/S involvement?
No doubt that with his history and response to mobilization and treatment of the T/S there might be an additional “crush” in this region. But, I would watch those neuro findings VERY closely and let this guide your treatment.
How long would others wait before making a referral with an absent achilles reflex and inability to complete a heel raise? In an acute situation, Meadows talks about the hours (48-72) you have before cell death occurs. This situation sounds a bit different, but thoughts on this?
Example of misleading stats:
AJ and I just ran the stats on our current manip vs sham study on neurodynamic mobility. Interestingly enough, both groups (manip and sham) statistically improved regardless of intervention. However, the effect size for the lower quarter/slump was much stronger for the manip group than the sham. At face value, while the p value did suggest statistical significance, was this clinically meaningful? The confidence interval was very wide and almost included 0 in the sham group and was much better represented in the manip group. So, despite a statistical significant value, looking more closely at the data might lead one to propose that this finding is not clinically significant. Sometimes these numbers can remain hidden when presented without some context. It was brought to our attention that this was a good example so I thought I would pass it along.
#TexasInstruments, #TI-82requiredThe owner of our clinic in Winchester also has a degree in counseling. What is interesting is that she has been doing much of this type of intervention for years, long before it caught fire in the profession. When I was just starting as a new graduate, I used to treat in the room adjacent to her to listen to how she interacted with patients. Through her connections, the clinic also has established a relationship with a local psychologist who specializes in pain. They also have a “pain group” which we have referred patients to in the past. It is great to have this outlet, but you obviously have to be certain you select the appropriate patient for this and they are “ready” mentally for this angle of treatment.
Nick – You are correct in that an anteriorly displaced/translated distal fibula occurs with a typical inversion sprain and is a common dysfunction found in CAI, no doubt. My comment to Oksana is that if his symptoms have been there for 5+ weeks that whatever ligamentous disruption there was may be not be the limiting factor now and causing his lack of DF and/or Inversion ROM loss. In an acute sprain a posterior glide on the distal fib does increase length/tension on the ATFL. However, much like many of the other Mulligan techniques (which sometimes work in an opposite way from what would mechanically make sense, such as a lateral tibial glide with knee flexion in WB), ROM into inversion, even with an ATFL injury does improve with the MWM technique in a posterior/superior direction. I think in an acute ATFL injury, a posterior glide to the distal fibula is typically painful, as is palpation in the area generally. However, limitation in inversion ROM is often improved with a posterior glide (if this is tolerated). Since this situation is not acute, I would suspect that the posterior glide would not hurt and likely be needed and also, likely improve his inversion ROM loss. Hope this makes some kind of sense.