[awilson12]

I think that using outside resources to address difficult topics is a great way to start the conversation as well as address different aspects that you don’t usually think about or consider. So definitely open to any and all resources to help with this!

Stress in particular isn’t necessarily hard to ask if someone is experiencing and I find that a lot of people can identify relationships between stress and pain. But what is difficult is nailing down specifics of their stress, methods of stress management that they have tried that work and don’t, and offering more suggestions on other ways to cope. Additionally helping them make the connection between stress and pain to where it just isn’t a concept but something that can be used as a treatment strategy for pain is difficult.

I like that in this inventory they address the pain and stress relationship in an understandable and relatable way. I also like the checklists that can provide a good visual to evaluate the number of stressors, how this manifests physically and emotionally, and strategies for preventing and coping with stress. I think that this won’t work for every patient because of the length but have a few in mind that would be open to reading and filling this out.

[awilson12]

I agree with you both that reframing questions for those with chronic pain about what people are thinking/how they are responding to our treatment is definitely beneficial. I like this way of going about it and am curious to see what the outcome is experimenting with implementing it with different patients.

I am on the same boat as you Barrett in that I don’t put a lot of stake in pain numbers but get them at evaluation and reassessment points (sometimes) for documentation purposes. I think I can do a better job of recognizing inconsistencies in pain report and outcome scores and using this to challenge beliefs rather than just moving on.

I think I only really ask pain numbers specifically with post-op patients to get a better idea of the degree of pain with exercises and if it is a “safe” pain versus something that needs to discontinued for the time being.

[awilson12]

I feel like a lot of times people are able to relate increased pain with increased stress, but getting them to really understand this and steer them away from the “something must be wrong” mentality is tough. I have tried to change my education in these situations to be more reflection for the patient and a conversation vs spitting pain science at them. Still a work in progress and patient dependent on what is successful.

I’m not sure that when the click happens within the range changes a whole lot treatment wise, but I could definitely be off on that. From my understanding a click usually represents the disc translating/moving at inappropriate times. If it is a motor control type issue or due to hyper or hypomobilities on either side then you should treat those impairments and reassess.
Anyone else have thoughts on this?

[awilson12]

Subjective questions:
– want to know more about headaches (see if they are cervicogenic in nature and joint vs myofascial)- are they unilateral, where exactly are they, are they associated with n/v, light intolerance, etc, any neck pain associated with these
– does she feel like her jaw gets stuck/limited in range of motion (can help to differentiate disc displacement w/ or w/o reduction going on)

Thoughts on addressing psychosocial component:
A good starting point may be asking her if she has noticed any relationship between increased pain and increased stress/emotions and then this may be a good lead in to starting to get her to realize the multifactorial contributions to pain

Treatment:
I think that care needs to be taken with education and treatment to address psychosocial contributions while treating underlying impairments that may also be contributing

[awilson12]

Barrett- curious to see how your conversation went with this patient when you called him back?

[awilson12]

1) I don’t think that is a particularly narrow search strategy but just playing around with wording and the terms you use could be useful to get more results.

2) Strengths: decent sample size, no differences in baseline characteristics, randomization and allocation to groups by researcher not involved in treatment or assessment, specific explanation of techniques used
Weakness: between group for NDI statistically significant but results didn’t meet MCID, recruitment from single clinic, only looks at 1 week time frame

3) To me this article shows that there may be some improvement in self perceived disability in the short term with the addition of manipulation to adjacent areas, but overall the addition of thoracic and CTJ to c-spine manipulation didn’t seem to be better. I don’t know that this specific article justifies a significant benefit of doing this all in combination, but I also think that there is other research out there that does identify the benefit of thoracic manipulation in patients with neck pain.

[awilson12]

I would agree that this guy seems to be a coper. He has been living with this for at least 7 years now and has had less than one episode a year only with higher level activities. Just out of curiosity, why did he decide to come to PT now after all this time?

Recently listened to a Clinical Edge podcast talking exactly about this. Some main points from the speaker that I took away:
– in some European countries there is a push for a trial of rehab for individuals before considering surgery 1) b/c outcomes for surgery are going to be much better with prehab and 2) b/c this may identify those who are able to cope and avoid surgery. Based off of empirical evidence mostly it seemed that this has been pretty successful for those who go through both op and non-op courses. So, in your case Barrett, either way it seems an initial trial of PT is the place to start (and likely the solution).
– his education for all ACL patients was the increased risk for OA progression with ACL-R and helping them to make an informed decision knowing this (however, admittedly don’t personally know the research on knee health down the line for op vs non-op)

I have not personally rehabbed a coper, but it makes sense to me that it is going to be a similar progression and focus as post ACL-R. For this guy, you skip the initial phase of controlling swelling, working on ROM, etc. and get to jump to focusing on higher level NMR and quad strengthening. I think coming at it from the mindset that he is lacking passive restraint so he needs increased strength and control to make up for this is helpful to guide exercise prescription.

[awilson12]

Similar to wrist, I don’t have really any clinical experience with the hand to go off of. Drawing from my limited knowledge base and based on the J of Hand Therapy article it seems like there were good outcomes with patient specific splinting prescription, so I think it would be worthwhile to refer out to get that done since I don’t personally have the skill set to effectively help with this. In terms of referring to ortho I think this depends on the severity of pain and disability, the patients interest in pursuing other options, and/or progression with PT.

Using reasoning based off of other OA populations and the articles you provided management would likely include activity modification, joint mobilization, and mobility and strengthening in and around this region within appropriate pain levels. Potentially more severe levels of OA will not get as much benefit and relief, but it seems like (at least within the 4-6 week range) a combination of splinting, education, manual therapy, and exercise can provide the patient with pain relief and functional improvements.

I have had very few experiences with hand surgery- have only spent a couple of hours with our hand therapists doing pre and post-op consults through the UVA hand surgery center. I personally have not seen someone post-op and led them through rehab, so I have no experience to draw from to discuss outcomes in these patients. Would love to hear others experiences and take-aways if they have had experience with this!

[awilson12]

For us at UVA we are fortunate and have a hand clinic “within” our clinic, so I definitely wouldn’t hesitate to refer to them or have a discussion about a case to learn more.

I do think, though, that knowing other rehab professionals within the area that have a specific wheelhouse is beneficial and should be utilized if you feel that sending a patient to them is more appropriate healthcare utilization.

[awilson12]

A specific example of use of both systems-
I had a patient that presented with a lateral ankle sprain and was able to use a lot more system 1 thinking and pattern recognition to guide my subjective and objective examination. However, when things were not progressing as I had experienced before in similar cases and based on my expectations for this patient I had to shift to a more system 2 type approach and further problem solve as to why this could be.

I think in general I am still very much a system 2 thinker but can see how important reflection in and on action is to shift thinking and develop clinical patterns. I think as new practitioners it can also be easier to fall into more bias when utilizing system 1 and harder to recognize this bias sometimes too. So, while it is not always the most efficient, I think developing a solid system 2 vs rushing the “shift” is important.

[awilson12]

I think this brings up some interesting points about “popularity” of articles, things that may be driving what is put out on social media, and the impact on how that affects lit searches. Personally I don’t know/understand a whole lot about impact factor, metrics, etc. so this hasn’t been something that specifically drives my decision making when reviewing articles. However, I now have a better understanding of specific journals that tend to put out more solid and trustworthy articles, and try and stick to using their research to guide decision making vs a more obscure journal.

Going off of what Barrett was saying, I think that with social media you are naturally going to follow people/groups that have similar ideology and biases that will just continue to feed into these things. Not always a bad thing but something to be aware of and not get caught up in these accounts being the end all be all.

To Taylors point of these types of metrics giving good information about “trends” in physical therapy- this is something I didn’t think about and is an interesting point. The types of things that are more heavily circulated can give insight to practice pattern and should drive the discussion of why these things are being “boosted.”

I think that social media can be a good tool to be exposed to new or different ideas, start a library of articles to read and critically review yourself, and help with treatment ideas. However, it shouldn’t be something that you mindlessly get information from without critically apprising it for yourself.

[awilson12]

Once all information is gathered and I have decided that it is something that needs to be further assessed, for example Keinbocks like a lot of others mentioned, then at this point it would be a refer and hold on treatment until I know more. I think that getting in touch with the PCP with your recommendations/thoughts and seeing what they would like to do would be good to ensure you aren’t stepping on any toes.

Taylor- from what I have read for AVN it seems like MRI is go to for this. Also with MRI I feel like it could identify other soft tissue/ligamentous injury if AVN is not what is going on, so could give good information in addition to subjective and objective exam to help guide management. Anyone else have thoughts on that?

In terms of bracing, this is not something I have a lot of background to go off of so not really sure. It seems like with this going on for at least 4 months that it might be beneficial to have a brace to limit use and extremes of motion to decrease irritability.

[awilson12]

1) I go back and forth with trying a more specific search first or a broad search just to see the extent of information out there. I feel like now I tend towards starting with a broad search then filter from there (year, more specific search terms, etc.). When I am between a few articles a few things that I use to guide my decision are comparing which article most closely answers the specifics of my PICO question, is recent, the strength of the journal it is published in, and which seems to have stronger methodology.

2) I think that all of the interventions are very much non-functional (could maybe argue a case for chops & lifts at least getting closer) in the CSE, PNF, and control groups. Also curious how 3×10 of trunk curls and leg extensions takes 20 minutes…

3) I find it hard to trust surface EMG for measuring deep trunk muscle activity and also am not sure that this has much merit in terms of relationship to pain, disability, and functional improvements.

4) The intro and discussion talked a lot about the importance of specific activation of deep musculature as being preventative and curative for low back pain and I’m not sure I can get on board with that reasoning for improvements seen in pain and disability in this study. Also the population was surprisingly narrow- mostly younger females with < 1 year duration of symptoms and low pain and disability.

[awilson12]

It is a good point that psychometrics are usually based on reference to “gold standard” diagnostics, but that even these are not great for specific identification of structures that are driving pain- leaving us with even more unknown about the true validity of special testing.

For the shoulder I don’t think I can say that special tests alone help me to feel confident in completely ruling in or out. I have found that having one specific structure at fault likely isn’t the case with a lot of shoulder pain b/c of the proximity of so many structures and likelihood of one specific movement to stress multiple things.

I feel like my pattern recognition is based a lot more on specific subjective complaints, functional assessment, ROM, and resisted testing with less of an emphasis on special testing. To be honest at times I feel like I am just doing it because that is what we learned but don’t put a whole lot of stock into the findings- something to evaluate about my practice and improve clinical reasoning on to determine if and how these tests can be used better.

I haven’t in the past used special testing as an objective asterisk and/or to identify and reassess irritability; is this something that y’all do often?

Steve- Did this article change your thoughts on utility of shoulder special tests in clinical practice? Is there any part of the exam you feel like you weigh the findings more to help with diagnosis and pattern recognition?

[awilson12]

A few take aways for me from this article:
– the importance of differentiating VBI vs CAD- the “scary” reports out there from manipulation are often in patients with artery dissection (at least that’s my understanding) and this article points out that these patients really should be identified from a good subjective history & there is no utility in these types of test in this population
– VBI is a result of multiple artery occlusion to the point that the collaterals don’t have the capacity to make up for lack of blood flow from one particular artery; I thought it was a good point to identify the weaknesses of studies assessing these maneuvers in patients only looking at single arteries

Do I perform VBI testing how it is written? No- it makes sense to me the method we discussed in the course series of progressive loading

Does this article help with clinical decision making? Yes- even with the progressive loading schema I think this article brings more awareness that this may be helpful in identifying cases of more “severe” VBI and that it may not have much utility at all in patients with dissections (I feel like previously I just grouped these differentials together and viewed it to be used for both populations)

[Author]

Posts