[awilson12]

Differentials:
TFCC lesion
Midcarpal instability
Distal radio-ulnar joint instability secondary to ligamentous injury
ECU or ED tenosynovitis or tendinopathy
Fracture- ulna, carpal(s)

Subjective questions: more specific location of pain, any clicking/clunking when moving wrist, pain with twisting forearm/wrist (opening jar/top/etc, turning doorknob, dressing, pulling off covers), positions of comfort

Objective exam: tuning fork, functional exam to observe movement (esp weight bearing), grip testing in various positions, quality and quantity of movement with AROM and PROM help w/ identifying any capsular pattern or specific movements that are painful or restricted, resisted testing to r/o muscle/tendon component, special tests specific to above differentials, palpation

A few things could lead to decision to refer to ortho for imaging: if not seeing improvement that expected with treatment, if concerned for fracture or significant instability that may warrant further intervention

[awilson12]

This is speculation and maybe a flawed theory but to Helen’s point of a very trivial trauma leading to a labral tear- I agree that doesn’t seem to match. But with onset of elbow symptoms first could that not being playing into changed mechanics at the shoulder that is revealing some underlying pathology? Any thoughts on this?

In terms of choosing testing clusters for labrum- I like how we talked about in the course and try to use that method during my exam. I attempt (still a work in progress) to take the patients aggravating factors and mechanism of injury and use those to guide special testing. Ex- a compressive type injury would lead me more towards using a cluster with compression rotation, anterior slide, O’Brien’s to mimic forces of MOI and challenge potential structures at fault.

[awilson12]

Helen to your point of getting blamed for bumps in recovery-
Respecting your referring surgeon by adhering to their protocol is important, but I also feel as therapists it is our job to extend our knowledge as movement experts to reason how to appropriately progress within the limits of the protocol. And then be ready to defend our decisions should we be questioned.

For example, RTC isometrics can be done in various ways (different angles, speed of movement, etc.) that can be viewed as “progressions” of the exercise that we can choose to prescribe if we feel like it is appropriate for that patient but are still within the protocol that is given.

[awilson12]

That information leads more towards anterior instability and labral pathology presentation, but still seems like there is some rotator cuff irritation as well.

A few other things I would want to know- irritability/tenderness with palpation of elbow and shoulder, range of motion normal or hypermobile?

How did you decide which special tests to use?

[awilson12]

Sorry a bit late to the game with this…

Based on everything we know so far differentials would be:
RTC referral (infra or supraspinatus)
Shoulder external impingement
Axillary or radial nerve entrapment
Humeral shaft fracture

A few other things I would like to know- what are alleviating factors for her, PMH “unremarkable” but anything in hx that would predispose to poor bone mineral density

Objectively:
Screen cervical spine and elbow
Focus more on shoulder- AROM vs PROM and resisted testing can give good information to determine RTC involvement, any patterns with movement, end feel, etc. to help differentiate
Central vs peripheral neuro assessment & neurodynamics

[awilson12]

– Great review of the anatomy and pathology of the foot and ankle that will help me with a more encompassing scope of differentials and better identify some of the pathologies discussed.
– Super helpful to go over a systematic approach to treadmill running analysis, and also relate that to research on effects of altering these parameters for a specific purpose in regards to patient presentation.
– Also will add some of the “physical performance tests” to my functional assessment to help with identifying contributing impairments to help guide treatment.

[awilson12]

I think studying and developing protocols is a difficult thing to do because of variability in patient characteristics and presentation as well as surgeon preference and variations in surgeries.

Protocols are good guidelines to help make decisions, but because of many different patient factors and specifics of each surgery it is so important to use clinical reasoning to help guide progression. Also the fact that, for example in this article, it is hard to find a consensus on protocols and there is variability based on surgeon/location just further stresses the importance of using our knowledge of healing timeframe, anatomy, biomechanics, and exercise progression to guide rehab.

I find articles like the one I attached (shoutout to Eric) super helpful in helping me understand procedures and guiding rehab.

Attachments:

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[awilson12]

Taylor-
How I relay these messages is very patient dependent. I am still learning day by day how to be a better educator and identifying specific characteristics of patients that can “handle” more specific explanations vs those that would do better without.

I tend to be very general with more emphasis on what sort of things the patient can do to help when there is a long history, multiple psychosocial factors, lower education level, etc.

Then, in contrast, some situations there are patients who want to know every little detail, and I have to spend a little more time going into things. I feel like in these situations, though, it is still important to watch what I am saying and give thorough education without unintentionally delivering a “nocebo” message.

What patient characteristics do y’all tend to associate with needing more care to not instill fear associated with education on your “diagnosis”? And on the flip side when do y’all feel more comfortable giving a more thorough explanation?

[awilson12]

P Barrett Coleman-
What was your response to those questions? Did she at some point have a better understanding and become less concerned?

[awilson12]

Taylor-
For sure agree. I feel like situations similar to this come up on a daily basis and it is always hard to deliver a balanced message dispelling fear without challenging them too much first visit. What have you (or anyone else) found to be successful in these situations?

In this particular situation I felt that initially with the patients history and her crying the whole initial eval building some rapport and decreasing fear would go a long way to then be able to educate more thoroughly. Second visit and third visit (when she wasn’t crying the whole time) I talked about studies that showed by age 30 up to 80% of asymptomatic people have disc bulges on MRI, the misconception of a “slipped disc”, and the relationship between the severity of symptoms and her past experience and current life stressors. She seemed to respond well to this and was less obsessed with the disc being pushed back in to cure all.

Was this the best or “right” thing to do? Likely not and I’m sure there are many other ways to go about it, but throughout treatment with this specific patient this approach worked for me. What would you have done differently?

[awilson12]

1) What do you think about my search strategy? Tips/pointers that you’ve found helpful for other literature searches?
It is definitely hard to find a broad enough but not too broad search strategy to get what you need; something I struggle with a lot. I find myself doing something similar in finding a somewhat relevant article then scanning the references, but this can quickly get time consuming.
You maybe could have tried “thoracic spine dysfunction” or just “thoracic spine pain” with a combination of other things but not sure that would have been any more helpful.

2) Read through my summary and the article, then let’s talk about statistics:
– What do you think about their findings in the results section?
It’s always fishy to me when authors present only certain parts of the data. The graphs and tables for the subjective information are helpful, but where is the same for objective? While not a whole lot was found to be significant with the subjective measure between groups, the graphs and charts give good insight to the trend of greater improvement in the SMT group. It would be nice to be able to reason through a similar process with the objective data as well (especially with such a small sample size).

– Did they draw appropriate conclusions based on the statistics?
I think the conclusion “This pilot study suggests that spinal manipulative therapy has greater benefits than placebo treatment” is accurate based on the reporting of some significant findings in the results section. I struggle with comparing the significant intra-group findings and saying that one group had “greater” significance compared to another; not sure that is a fair conclusion to draw when some of those findings weren’t necessarily supported by inter-group comparison.

– What are your thoughts on statistically significant vs clinically significant?
I think it is worthwhile when studies are good about including MCID’s to better argue clinical significance. With no mention of degree of improvement with objective measurements how do we know if this is even outside the MCID for that measurement?

3) Any other general opinions on the article?
I thought it was interesting that one of the inclusion criteria was “palpation of movement” to identify a “thoracic fixation.” I guess that was their way of identifying thoracic hypomobilities but seems like a very subjective “objective” inclusion criteria.
Also am curious on how they measured “naivety” to placebo treatments.

[awilson12]

Recently I had some success with placebo with a patient who was very caught up on the “slipped disc” that showed up on her MRI and was holding onto hope that PT would just push it right back into place because she didn’t want to have to get surgery. It was tempting to go full on with a patho-anatomical explanation and confront and dispel this belief. Taking a step back, though, in this situation it was more beneficial to use her beliefs that PT would be helpful and discuss all of the things we were going to do to strengthen her neck and disc. For her to hear another biomechanical explanation would have been doing her a disservice, and I think it was more successful in the end to utilize “placebo” for initial buy-in and more subtly educate over the course of multiple visits.

[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!

[awilson12]

1) Primary- mid cervical facet dysfunction; differentials- mid cervical disc pathology, myofascial involvement- upper trap, levator, suboccipitals

2) With not a lot of information or very specific aggravating factors it doesn’t help to differentiate much between my primary and differential diagnoses; with MVA more concern for vascular, fracture, or ligamentous disruption so adding that to my list of differentials

3) Doesn’t really fit expectations for a facet driven pattern but could be arthrogenic in nature- global limitations in ROM, hypomobile joint mobility assessment; would want more information about “red flag” symptoms with cervical assessment but feel better about ruling out vascular/fracture/ligamentous pathology; don’t feel like I have enough information to completely rule in/out other differentials

4)
Subjective:
Rotation one way or the other worse?
Sleeping posture?
Any pain with ADLs, looking up or down, sustained postures?
More information on MVA and care afterwards
Pain onset in relation to MVA? Immediate or delayed?
History of neck pain?
Imaging?
Red flag questions?
Psychosocial contributions/affect?

Objective:
Compression and distraction (in neutral, flex, ext)
L SB and L quadrants provocative for same area?
Palpation of suboccipitals, UT, levator
Provocation with UPA

[awilson12]

1) primary- PFPS; differentials- patellar tendinopathy, adductor strain, tibial plateau stress reaction/fracture

2) With PFPS and patellar tendinopathy would have expected more pain provocation with functional assessment, so doesn’t quite fit a pattern but potentially more in line with patellar tendinopathy due to pain with hopping and TTP

3) A few things-
– How long to alleviate after running?
– No mechanism of injury- does that include no reported changes in activity level?
– With patellar tendinopathy on differential would want to do resisted knee extensor testing for provocation
– Any sagittal plane deviations with squat, hop, etc? Only SL hop painful?
– Pain with adductor palpation or resisted testing?
– at follow up would want to get on treadmill and do running gait analysis

4) May consider taping and would re-assess pain provocation with functional assessment; exercise wise she seems to have pretty poor mechanics with most things so start targeting proximal weakness

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