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Something similar to this. Tension starts A to P on distal fib with a superior inclination and spirals around posterior fib and posterior-medial tibia.
What is his distal tib-fib mobility like? Sometimes this can help differentiate ATFL vs synovial tissue as the structure at fault. If he has pain with inversion, push his distal TF posteriorly: an ATFL sprain would not like this and would increase pain, non-ligamentous structures, such as his capsule/synovial tissue, etc. might actually like this and decrease pain and increase ROM ability into inversion. You can use this as a mobilization with movement technique as per Mulligan and follow it up with tape if effective. Distal TF dysfunction also may be relevant to his DF loss as well.
Just a thought.I think the problem with the dogma surrounding this concept is so multifaceted. One of the biggest issues is that we don’t have a much better, or at least well understood model of what really happens, to easily refute this belief. It is easy to educate someone who says something so obviously wrong that we can easily correct and support with good evidence why they are wrong. This simply is not the case with the mechanisms behind manual therapy. I think this is where the “rolling with resistance” idea comes into play with an attempt to gradually break down barriers that may limit your outcomes. The question may be – how much of this belief do we need to change, or is there a way we can utilize this belief to our benefit? Should this be how we are selecting who we complete more vigorous manual therapy techniques on or is this a red flag to avoid these techniques? How much a positive expectation and belief will impact our technique is likely more important than the possible biomechanical changes which may or may not occur. Check out this blog post below.
https://thesportsphysio.wordpress.com/2014/06/16/there-is-no-skill-in-manual-therapy-2/
Nice talking points, I love it. Think about what the foam roller from a mechanical aspect to – what does the thoracic spine need to do in order for scapular muscles like lower trap to be most effective?
With all of this motor relearning remember there are central processes occurring. Do not underestimate the neuroplasticity of some of these patients. Even though this citation discusses post-stroke rehab and those with chronic pain, some of the concepts are important to remember. “Strength training does not achieve the same effect as skilled training” – we are impacting the primary motor cortex with many of our techniques.
We utilize the PSFS, especially with our Medicare folks as it can be used to help determine functional status and reporting. We find that it is helpful when the outcome of some of the other scales, such as the OPTIMAL (which we use), does not seem to capture the patient’s level of impairment and need for care. The PSFS is not given to the patient on a sheet of paper but it is on our medical screening questionnaire but indicated that the PT will fill out instead of the patient. It is a reminder to ask their goals and limitations with regards to function, which we already do. The only difference is the numerical rating that the patient gives describing their current ability with that task.
Yikes….makes me wonder how many of these re-ruptured under my care in the old-school days of see them 3x/wk x 12 weeks with aggressive ROM and initiation of strengthening at 6 weeks.
Nice discussion you guys. Continue to work through some of the questions about the case today and tomorrow so that the discussion on Tuesday can be centered on the article itself. Sean, I think you bring up some very valid points about how we go about informing patients about particular techniques and how maybe the way in which we go about this (our attitude, tone, style, etc) may actually be more important than the actual information they receive verbally. At Kaiser the faculty would often say phrases like “is it ok with you if I give this joint a quick stretch?” and they would tell them they might hear a little sound like when you move your knuckle in a certain way but would downplay any audible effects and let them know that the quick stretch is really the important piece and seemed linked to change in the system. Sometimes patients are still surprised by the velocity of the technique and some sounds, which are certainly amplified in the cervical spine given their ear is so close. However, at least you have told them something and not completely withheld the intent of the technique. With regards to expectations about therapy in general I think some would urge to not wait until the end of the first session to ask this. Why not ask this as part of our subjective history intake as this changes our objective exam and treatment no different than asking about a particular aggravating factor or a red flag. There are plenty of textbooks that discuss rapport building and how important this is during the subjective and having this talk (their expectations) is an avenue to start that dialogue. I attempt to do this and then again at the end to make sure that their expectations were met. This seems to open lines of communication and I think also impacts their buy-in, compliance and cancellation/no show rate as well.
Nick,
Nice article selection – should make for some good discussion. I would love to hear some of the other residents thoughts on your patient presentation and your leading questions. I have some insight to offer after taking a look but want to hear others first. With regards to your expectations question can you give us an idea of her personality and what her understanding/expectations were?Aaron
This is a tough issue as we are certainly in a unique position to interact with these patients for longer periods of time per session and throughout their care. The idea that multiple systems need addressed and treated fits into our practice management philosophy and the product we “sell” patients. In fact, having another product to sell beyond the biomedical pole, gives us more tools to use and possibly help these patients who previously were the dreaded ones on our schedule. From a surgeon’s perspective, awareness of other factors beyond the biomedical possibilities, might only decrease the ability for them to sell their product (surgery, injections, more imaging, etc). So, perhaps, ignorance or oblivion is bliss in this situation from their perspective. You would like to think that when there is more robust research beyond the cohort studies than those available now, that practice patterns may change. However, do not hold your breath too tight. Even with RCTs with long-term follow-ups in their journal (Spine), indicating no improvement beyond therapy with an ACDF, the frequency of these surgeries is still increasing each year. I think we have to attempt to educate our referral sources and maybe find other avenues of education/marketing via pain management groups, local psychologists/counselors, support groups, etc. Here is the recent O’Sullivan article from PTJ and one I found from a spine journal (not Spine), that supports the notion of this management for chronic non-specific low back pain.
The recent shift in management style and awareness of psychosocial aspects of patient presentations that impact our care is wonderful and it certainly is becoming more of a hot-button topic in the literature. Educating ourselves and our patients and having methods of doing this is obviously necessary. I am wondering, however, if any of you have had to discuss this aspect of assessment and care with referring physicians or surgeons, and if so, what their response has been. I was talking to a local neurosurgeon last week about this and asking if they do any assessment of psychosocial behaviors or yellow flags and take that into consideration when determining if a patient is a surgical candidate. He seemed to be aware that obviously these behaviors impact outcomes. However, his comment was that, “crazy people, can still have pathology.” I understand his comment or at least what I hope he was trying to say, but, am wondering how we can best educate other providers of this important concept and how vital it is to assess and address. Thoughts?
This article brings up an important view of our ability to assess PS factors. Ultimately, we know we are treating the entire person and this includes the PS factors, but how often do we feel comfortable and confident in tackling this. Like the article mentions, some PTs feel most comfortable to screen or go with a “gut feeling” or refer if need be. I have to say that the hardest part of working this past year is understanding TNE and effectively and confidently using it in practice. Our owner has her Masters in Counseling so she is always giving us “tips and tricks” on communicating with patients about pain and how to have a good evaluation process that supports building a relationship with your patient. From the book, an interesting article (Hoffer Gittel 2000) compared the efficiency and outcomes of nine hospitals with respect to joint replacement surgery. Some invested heavily for training in “relational competence” versus investing in highly qualified surgeons/physicians. The study found significant differences, in that the hospitals trained for “relational competence” had a 31% reduction in length of hospital stay, 22% increase in quality perceived, 7% increase in post op freedom from pain, and 5% increase in post op mobility. This went to show me that I can work and work on mastering a technique, but it may not produce the benefits as significantly if I have not addressed the patient’s PS factors.
I think this was actually a really cool article because recognizing biopsychosocial behaviors in our patients and providing pain education is such a hot topic that’s getting more and more attention. I think this is a huge area we can grow in as a profession. Pain is the number one reason people come to physical therapy, so if we can do whatever it takes to positively change someone’s pain experience, whether through exercise, manual therapy, or education, that’s a win for our profession. Therefore I think addressing psychosocial issues with our patient’s best interest in mind, then that is something we most definitely have a role in.
What stood out to me the most was “the most consistent barrier highlighted was participants’ lack of formal education in PS theory and assessment.” So I thought it would be a good idea to send this paper to one of my professors in grad school with that sentenced highlighted to see what his thoughts are since he is an educator in our profession. Fortunately for me, I think my PT program did a good job at exposing us to this issue. I think it helped that one of my professors did a lot of pain science research. It also helped that one of my clinical instructors encouraged me to read “Explain Pain” by David Butler while I was on one of my internships. So luckily, I can’t say I didn’t learn this in school. However, one of the biggest things I struggle with is addressing psychosocial issues with formal measures when it’s not just chronic low back pain. It’s easy to use the FABQ with these patients to help gauge their mental state, however, we currently don’t have a questionnaire that can be used for other chief complaints like shoulder, knee, hip, etc. I also don’t think patients have to have chronic complaints to be included in this group.
I really do think if we can improve our capability of addressing the psychosocial aspect negatively affecting our patient’s pain experience, then we have the potential to really improve our patient’s outcomes and satisfaction of care.
I was a bit surprised by this article at first- it was shocking to read some of the comments (especially from the more experienced therapists) and learn how little they understood psychosocial issues and their impact. It did make me reflect back on my first year of practice though and I can honestly say, I wasn’t far off from them.
I learned about “yellow flags” in school which essentially meant listening for these in the subjective. I did learn about the FABQ but I feel like I never truly understood what it meant scientifically to have psychosocial factors influencing recovery. I think for many young PTs, high FABQ scores could be interpreted as the patient was exaggerating, or they had other intent for financial gain, etc. I can sadly say I had this view initially (and I even had some education on this in school)! I think for me, despite being educated in school, there was no carryover on clinicals and in my early clinical practice to apply this material and learn it in a clinical role. My first job was in a very low income, low education area and everyone had 10/10 pain and nothing seemed to fit a clinical pattern. I would listen to the PTs around me joke about these patients and it began to shape a view in my mind that was not accurate about psychosocial factors. This patient would walk in the door and I was immediately frustrated and did not give them the benefit of the doubt- I already knew they weren’t going to get better because they “didn’t want to try”. I think had I been surrounded by good mentors who further educated me how to recognize fear avoidance and psychosocial factors impacting recovery in the clinical setting (not just in a lecture) and how to manage it, I would have been much more successful treating these patients.
I think what differed about the education I received in school and the education I received in VOMPTI was the emphasis on therapeutic neuroscience education. This definitely changed the way I viewed these patients and in turn, made me much more successful with them. In grad school, I was taught about high FABQ, graded exposure, graded exercise, etc. but I did not have an understanding about WHY people had these views. I did not know any of the science behind it- the changes in the brain, etc. I think because of this, I had more of the mindset that these patients had alternative motives, etc. When I finally learned about TNE, I didn’t look at all these patients with frustration. Instead, I was able to be empathetic. I was able to explain to them why they were so frustrated as well and I was able to make progress.
I definitely agree that education in this area needs to be better. And it needs to be comprehensive. If you only receive part of the picture, you’re free to draw your own conclusions about the rest. And if you are not influenced by good PTs/mentors early on, this can be very detrimental.
Great thoughts, Casey! I agree with you that sports-specific training is best for NM control. We have been working on some running-specific exercises (which I hope will have NM carry-over to running). We’ve been doing single leg squats to bias glute activation and mimic running as well as alternating hip flexion/extension against wall to work on lumbopelvic stability and glute activation. If anyone has any other good running-specific exercises I’d welcome any suggestions!Thanks!
Thanks for your comments and questions, Cameron! I did a lumbar screening during the initial eval which included lumbosacral AROM w/ OP, quadrants, slump and SLR. All of these were negative. I did not test the peripheral nerves or add in thoracic SB with rotation during slump. These are great suggestions and I will perform these tests when I reassess her next visit. Her single leg calf raise was equal bialterally in terms of excursion with no symptom reproduction.
I agree with everyone’e suggestions that working on strength and NM control prior to gait retraining is the best way to approach this case.