Forum Replies Created
-
Posts
-
Oksana – I did an internship at his clinic so I admit there is potential for bias.
I wouldn’t necessarily use that terminology with patients (depending on personality etc), but I think being more specific with classification will help in regards to treatment/POC and communication with other PTs and MDs.To be honest, I never tried to distinguish b/w which one is working more and I’m not sure how I would, or that I could. Depending on the injured hamstring, I might modify positioning to affect muscle length of specific parts (i.e. bridge with slight tibial IR/ER etc.), but haven’t tried anything beyond that. From my understanding, the thing to keep in mind with the L-protocol is that early on scar tissue tolerates less tensile forces than the muscle and that’s why you’d want to keep it pain free, while still loading the muscle in the available range. I wonder if creating low level tensile forces would actually facilitate improved scar tissue formation, similar to benefits of axial load on bones.
Great point with the neurodynamics! Perhaps a reverse slump would tell you more since you’re already taking up the slack in the LEs and then adding C/S and T/S FLX. If positive, I’d be really interested in seeing how addressing that component changes his symptoms.
Sean – I don’t see a lot of runners… have you (or anybody else) worked with a lot of long distance runners who incorporate sprinting?
Thanks for posting Oksana!
In regards to PHT vs. strain I’d first want to know whether PHT is in the reactive, dysrepair or degenerative stage and treat accordingly (based on VOMPTI ankle lectures and running med conference); if it’s a strain/muscular pathology, I’d try to be as specific as to what type of m. pathology it is. The below article has been very helpful for me to distinguish between the types, how to approach them and what to expect in regards to prognosis. Also, one of the authors was interviewed for a BJSM podcast a few months back.
I’ve used lengthening exercises early on with several pts if tolerated, but with high irritability, I’ve also used prolonged isometrics with progressively lengthened position of the muscle(s), similar to tendinopathy pts.
It would be interesting to see how this study would play out in a population not consisting of elite athletes. That being said, as long as the exercises are performed in a pain free range, I don’t think that should make a huge difference. I’d just expect significantly different levels of performance depending on the pt.I’m also wondering how the lengthening protocol would work for pts with stretching type injuries (all subjects in L-protocol were springing type).
In regards to higher frequency of injury towards the end of the sessions, I would think that would be an issue to be addressed with the coaches (in the study) and with pts (if applicable). There have been some studies recently regarding training intensity and although injury prediction is a pretty controversial topic, it’s a good start. (see below and Gabbett also has a BJSM podcast worth checking out).
The studies Askling did were with sprinters/jumpers and soccer players, so I don’t know how that would translate into long distance running. Also, the soccer players did better in regards to return, likely due to the fact that they can avoid sprinting at max effort if need be -> possibly earlier return for long distance runners? Would be interesting to see how intensity vs. repetitive load differ in outcomes (if at all).
Thanks for posting Laura!
Did you slump him after you found the thoracic involvement? Did your primary hypothesis change after the thoracic findings? Did you give him any exercises for his T/S?
1. Sounds like there’s some increase in dural tension in that area (did you re-check cervical FLX/EXT at end range lumbar FLX) and sounds like he responds well to treatment at the T/S. I wouldn’t assume that there’s much more beyond that, besides possibly decreased T/S ROT after those incidents, which very well could’ve let to compensatory increased L/S ROT over the years.
2. I’d base the neurodynamics on irritability and severity and how long it takes for symptoms to subside after he aggravates them. At this point, I’d definitely stick with very low level sliders. How would you rate his SINSS?
3. Especially with someone like him, I’d make sure you’re on the same page regarding his activity level and exercises, just to control variables as much as possible. It sounds like he’s still able to do a lot so I would start him in functional positions and something that still challenges him sufficiently, but definitely with the understanding that he should cut down his own exercises (to a certain extent) so you can figure out whether/how much your intervention changes his symptoms.
4. I think that depends on how quickly he can see improvements. If you treat something and he demonstrates an immediate notable improvement in regards to strength (I’d focus more on that than sensation), that might give you a better idea as to what his prognosis would be. I’d definitely educate him on nerve healing times and how that process can take weeks-months.
5. Certainly not at the beginning; main reason would be that a manipulation seems to have triggered his symptoms. Also, seeing how easily you reproduced distal symptoms with T/S PAs, I’d definitely stay away from Gr V for a while. In the meantime, you’ll have a chance to see how much he associates his onset of symptoms with the chiro’s technique and how he feels about it. Either way, it seems that non-thrust techniques have already improved his symptoms, so I don’t think the risk/reward would make Gr V worth it at this point.
“some people stay healthy because of their movement pattern, some people stay healthy despite their movement pattern, some people fail to stay healthy even in the presence of a good movement pattern”
– A lot of impairments we treat that have a pathophysiological impact on a patient could very well make no difference in somebody else with the exact same impairment.” the ability to predict injury is low because they aren’t actually screening the tasks that they need to be able to do”
Also, the study included a vast variety of subjects with different activity levels and demands (although not clearly specified). I don’t know if a study like this can really show any specific results considering the design…
Having tools like the FMS is helpful, because it can show certain limitations, but I think it’s then the PT’s job to determine whether or not these limitations are meaningful (impairment vs. importance).
This reminds me of some of the discussions about Tim Gabbett’s work with training loads.
Considering the number of possible factors for injuries, there might be use in performing tests like the FMS, if it’s taken for what it’s worth and then used in the context of the individual’s environment, demands, activities and physical attributes etc. etc.Great discussion about how to approach the subject! A lot of times I’ll tell patients that I’m generally biased towards PT, just like the surgeon is biased towards sx, but that there are definitely instances where sx is needed, or provides better outcomes. Leading with that usually helps me set up the rest of the conversation and most of the time the patient will immediately weigh in on what their bias or preference is. (I haven’t had a lot of people tell me that they’d rather have sx)
Especially, in cases where there’s not a lot of conclusive research on what the best approach is, I tell the patients that there really isn’t a good answer, but what the implications are and what I have to offer them.
I like Richmond’s point and I think it depends on severity of findings. Another question would be would you change your treatment approach just based on imaging findings, or would you still treat the same way? Also, do you think that the labral tear affects his improvement, or response to treatment? I think especially with a pt who is worried about imaging findings it helps to have the conversation whether these findings change anything in regards to what the treatments look like or whether you’d make changes to the imaging findings vs. your objective findings.
As for the prognosis/duration question… I’d try to answer that relative to your findings, i.e. tissue healing times, time to see neurophysiological changes/improvements in motor control, gaining strength etc.
While that may not be a straight forward answer, it helps outline what you can offer and what he can expect time wise for different goals in therapy.I’d also emphasize that 1. PT before sx wouldn’t be a waste of his time and could improve outcomes, so he wouldn’t loose anything if he’d try PT first. That way he could always determine whether or not he really does need sx based on his personal outcome. 2. He’ll likely have PT after sx and 3. sx is another trauma to the system that he’ll have to recover from. What could help is showing him, or telling him about post-sx protocols for what sx he’s expected to have.
Based on his activities (run/swim) he doesn’t fall into the group for which sx is recommended despite his age, which is something I’d also emphasize.
Great discussion!
And thanks for sharing that post Kyle. I really like that mind set and I’ll def try incorporating that.Regarding the inversion sprain… we had a guest speaker in PT school on Mulligan techniques and he was talking about using posterior distal fib glides in acute ankle sprains if tolerated. We had a kid in class who had sprained his ankle 2 days before and despite the technique not being too pleasant, he reported significant decrease in pain generally and with ambulation. Obviously anecdotal, but the point is, I think based on pt presentation and tolerance, it might be worth trying. Thoughts?
Also, that specific technique was a sustained posterior glide with repeated active inversion.
I think Adam did a subpar job at getting his point across. It seemed that at times he was saying that the mechanical aspect of performing a technique does not require skill or special training (laymen being able to perform a technique without formal training etc.) and at times suggesting that clinical reasoning and appropriate application of techniques does not matter. I can see his point if he’s trying to say that all the manual techniques in the world don’t make a difference if you don’t know how to apply them, both on a clinical reasoning and psychosocial level. Recognizing a pt’s beliefs and educating/rolling with resistance and adjusting treatment accordingly has been one of the biggest learning experiences for me throughout the residency; also recognizing when a technique may be appropriate objectively, but may be something the pt isn’t too thrilled with. While there are some larger studies suggesting that specificity of treatment may not make a difference (vs. early intervention) and more recently Petersen et al. (JOSPT – see March review), there are plenty of studies showing the benefit of manual therapy (in combination with therex of course).
Another aspect that may be lost in the research framework is whether specific MT is ‘more better’ than non-specific intervention. If we’re looking at MCIDs and statistically significant changes, the other end of the spectrum may be lost – i.e. improving 80% vs improving 50% etc.
Adam’s points make more sense if one looks at MT as a purely mechanical intervention, however, I think we’d all agree that there is much more too it when considering psychosocial factors, neurophysiological and even systemic effects of treatment. Adriaan Louw talks about the endocrine system in combination with the nervous system and its role in regards to biochemistry in chronic pain. Moseley did the functional MRI studies of the brain and showed how education alone can change brain activity on a short term basis and who knows what else can be affected with education. Using manual intervention in this framework and using the physical experience of feeling the change that can be made after MT (assess/reassess) as an educational piece seems to bring much more value to MT and I’d venture to say that this does require skill. I think for most people it’s one thing to hear information, but another to experience what this information means. Just today, I told a pt about the MRI studies on pts with chronic LBP, watching somebody else bend over. He was right on board and told me how he can relate, because his back hurts just watching his kids jump around etc.
Sorry for the rant. But to answer question 1. Yes I do assess/reassess and yes, I’ve seen differences in regards to vigor of techniques making a difference without changing other factors.Myra – thanks for sharing that example. Aaron made a good point about rolling with resistance. I think some people get it right away, some need X different examples/metaphors, some need the experience, and some won’t change their beliefs regardless of what we say. Trying to figure out who’s in which category is certainly an art and probably somewhat of a gamble at times.
In one aspect I certainly agree with Adam… there are still plenty of PTs who think in strictly mechanical terms and focus on things like left-on-right rotations etc. without addressing the bigger picture and at the same time, feeding into or creating some of the beliefs we talked about.
A lot of times I’ll ask a pt what they mean when they use some of these terms (while not trying to sound facetious), both to figure out what it means to them and where they may have heard it. I think understanding what their specific belief or association with a word is and where it comes from makes the rest much easier. I like metaphors that don’t involve any structural terminology or words indicating damage – i.e. LBP if the T/S and hips don’t move well, I’ll talk about the teamwork between the structures and how parts of the team not doing their job, the others (L/S) will have to pick up the slack and will get upset/angry etc. Then exercise becomes a something that helps the L/S to pick up the slack, while mobilizations of hips and T/S becomes a way to make the rest of the team get off their behinds. This kind of metaphor, in combination with education on normal findings/changes etc. has worked pretty well for me. I also use analogies about the brain being a computer a lot, with chronic pain or movement patterns being programs that need to be updated.
Here’s another study that has set off a few light bulbs:
http://www.archives-pmr.org/article/S0003-9993(04)01323-1/abstract
Great points! I def agree that there are a lot of problems with that even within our profession. I just evaluated a pt (C/S radic) who kept saying that he blew out something in his neck. I asked him about it and he said that was the language that was used by his previous PT (who treated “lat epicondylitis” without looking at the neck for 6 weeks). The pt said he associated that terminology with his patellar dislocation years ago. Luckily he is very receptive and cerebral and the discussion went in our favor, but more often than not it’s not that easy.
I have another pt who’s been to the chiro weekly for 10 years and he certainly is not one who’d appreciate a confrontational discussion about his back excursions. I think with pts like that it’s just about chipping away slowly and educate every visit.
Nick – thanks for posting! I almost always talk about sleeping patterns with pts, because I feel like it often helps me guide further assessment, but I’ve never used anything like that. Definitely going to give this to a few of my pts!
Thanks for posting Laura!
Lots of great points already and I fully agree with some of the mentioned additions like slump, quadrants (maybe not day 1 since you already reproduced her pain; I tend to include quadrants regardless, to check for combined motion and with suspected instability, move to H-I test from there) and the more specific palpation and mobility assessment Sean mentioned. I def like the idea of using standing compression and if positive, working on neuro re-ed right away.
I’d also include prone instability test on day 1. It seems that her irritability is low enough to tolerate PAs and I’ve found that the PIT helps tremendously with buy-in because it shows the pt a way to instantly decrease their symptoms. That also allows for a great transition into therex education and could help with HEP compliance. Did you clear the hips? I wouldn’t be surprised if her EXT and PAs would be limited considering the mechanism/biomechanics.I wouldn’t have been too concerned with the Hoffman’s alone. I was in class with Aaron the other day (cervical eval) and one of the PT students had a positive Hoffman’s (and Aaron had way too much fun with that) and it opened my eyes to how this can be a (+) in completely asymptomatic individuals. 2 weeks ago, I definitely would not have been as certain. If cord compression or UMN signs would really be a significant concern, I’d probably add cervical ligament testing as well, especially in a pt like that who likely has more ligamentous laxity as it is.
I don’t think that once a month is a great idea initially, especially in more acute cases. Considering how much neuro re-ed and motor learning is involved, especially at the beginning, I wouldn’t consider the idea. Also, I’d want to make sure that I can progress the treatment as needed, which would be difficult to do. If an exercise gets too easy after 1-2 weeks, I also have a hard time expecting the pt to be fully compliant. If it were a patient with chronic pain/limitations, where I know that the tissue healing time etc. is considerably longer, I think it can definitely work. I have a few patients I see on a very low frequency, but that’s always later in the course of care.
Nick – one cue I use for shoulder elevation is “keep your shoulder away from your ear” or “keep the space between shld/ear open”. I guess that’s not really an external cue, but that seems to work for me.
Eric, Aaron – thanks for the articles! I like the specificity in the first article and will have to try that.
The second article talks about pain being an inhibitor to cortical changes and skill acquisition and how total number of repetitions within a session don’t seem to be as relevant as quality of movement. I’ve found myself prescribing less exercise, but more specific to the pt’s problem, as well as focusing more on motor control and it seems like that’s made quite a difference. It also appears that HEP compliance is much better with less volume and increased specificity to the individual (also discussed in my March article review). I’ll def try to focus more on goal oriented cueing and exercise as discussed in the second article.Aaron – I would say it helps facilitate thoracic extension, scap tilt and improves the length tension relationship of the mid and low trap. It should also allow for more movement of the scapula in general since the scapula isn’t in direct contact with the bench. Close?
Nick – great point with scaption/UT activation. In most of these patients I focus more on the motor control aspect. I haven’t tried a whole lot of mirror feedback but that’s a great call.
Oksana – I like your notion of decreasing tone followed by movement. Over the last few months I’ve gone from trying to avoid movements that involve hypertonic musculature like the pec minor (or iliopsoas in LBP patients) to attempting to address hypertonicity manually and using exercises involving those muscles with improved motor control/movement patterns. It’s hard to say whether that’s right or wrong, but it seems to work pretty well.
I wouldn’t avoid an exercise just because it increases activation of a specific muscle, as long as the movement pattern/motor control aspect doesn’t suffer. However, it is good to have studies like these that help target some of these other muscles more specifically.I’m curious about the elevation + ER. I’ll have to try that myself tomorrow.
One exercise I’ve used with more advanced patients is a modification of scarecrow in prone, in which I have the patient separate thoracic extension, scap retraction, shoulder ER and UE elevation in sequence to focus on the motor control aspect. I’ve never seen any research on that, it’s just something that’s worked for myself.