[awilson12]

Taylor-
I think that it is patient dependent for my assessment/reassessment based on goals of the treatment. For example, if I am doing a manual technique for range of motion improvements then I will look at just that; compared to a technique for pain alleviation then I might assess range of motion still but look for any changes in quality of movement and pain reproduction.

Where I struggle more is identifying more functional assessments to look at pre and post treatment that I would expect to improve with whatever manual therapy technique I am doing. I think that being better about this can help with patient buy-in and also reassessing subjective asterisks as well as objective.
Anyone else in this boat and have helpful tips on how you have worked to improve this?

[awilson12]

I think this was really well done to challenge practice patterns of this region with good support from the literature. I feel like a few quotes really summarize common poor clinical reasoning, which is contrary to current evidence, of diagnosing pain in this region-
– “Frequently, movement dysfunction of the SIJ is credited with being a driver of increased local tissue sensitivity and subsequent symptoms. The biological plausibility of reaching such conclusions based on movement detection and palpation of the SIJ has been questioned for more than 10 years.”
– “…although clinicians commonly seek to identify movement dysfunctions on the basis of such tests, weight of evidence has not changed in the last decade and the use of these tests and models of movement dysfunction testing of the SIJ remains unsupported.”

A personal challenge for me in clinical practice is delivering a message of the inherent stability of the spine and educating on benefits and intention behind exercises that I am prescribing. This becomes even more challenging with patients who are hanging on for dear life to a pathoanatomical diagnosis from Dr. Google, imaging, another healthcare provider, etc. I found some of the specific examples they gave for educating on pain in this area and treatment rational very helpful (ex: your spine/SIJ is a strong structure and the pain you are experiencing is due to increased sensitivity of this area; sensitive tissues respond well to load; manual therapy to decrease sensitivity for exercise participation), and also provide a good “template” that you can change to make specific to other body regions and patient presentations.

[awilson12]

I definitely try to make reflection a big part of my practice, but the more difficult aspect of this is going beyond just reflection and changing practice patterns. There are for sure things that I have reconsidered and ditched over the past months, and things that I have adopted and changed as well. But there are also still times I find myself doing something that I am not really confident in or don’t have a solid rationale behind just because it is something that I have learned from another PT along the way or because I am at a loss on what to do. It is a work in progress, but being intentional about changing this is something that I have been focusing on.

In particular I feel like my practice patterns when it comes to low back pain and neck pain are something that I have been struggling with because of the amount of conflicting literature, variability in practice patterns, and complexity of many of the cases. I find myself sticking in similar rhythms for a lot of these patients and know that I should be better but struggle on how to get there.

Being reflective and adapting our practice to changes in standards of care is easier said than done, but by not doing this it is doing our patients a disservice.

[awilson12]

My only experience with a bony lesion was in a younger male with an osteoid osteoma near his femoral neck. His main complaint was severe night pain (he already had an ortho appointment lined up for a few days later so that made it easy to refer out), but he also had some myofascial contributions and patterns of hip weakness that were consistent with an overuse injury. Me and my CI ended up treating him some to get him back to prior level of activity and they were exploring if any further steps were needed to address the osteoma (it was super small).

A few questions for you about this patient-
Any increase or change in activity leading up to the onset of symptoms?

What is her level of understanding about non-ossifying fibromas and her affect/outlook on this?

More out of curiosity…
1) Did y’all have any theories on why the boot increased symptoms?
2) What did your education look like day 1, and does reading these articles and being more familiar with the diagnosis change education in future visits?

[awilson12]

1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?
AC joint pathology, labral pathology, RTC or biceps tendinopathy or tear

2) Are there any objective tests you feel would provide a clearer picture of this case?
horizontal adduction and AC joint compression test; passive range of motion and joint mobility assessment to determine cause of end range limitations

3) Do the objective findings fit a clinical pattern? If so, of what?
Based on this information seems like findings are in line with shoulder instability with associated labral pathology and RTC involvement

4) What impairment or limitation would you want to address first with this patient?
I would tackle the RTC weakness first to get those muscles turned on to help with shoulder stability

[awilson12]

1) Upper lumbar radiculopathy

2) Primary = hip OA; differentials = myofascial referral (iliopsoas or quad), upper lumbar facet referral

3) Other questions:
– Same aggravating factors for both areas? If separate then would lead to further questioning and suspicion about multiple things going on
– To help rule in OA would want to ask more about 24 hour pattern and pain reproduction- How long have AM stiffness and what helps? Immediate onset of pain with WB or how long to come on? Better or worse when do more? –> would expect that AM stiffness improve with movement but then worsen with too much activity, with aggravating factors potentially immediate onset of pain that improves over time but again worsens with large amounts of activity
– Questions to help with myofascial- For aggravating factors any specific points that are worse? Ex: with iliopsoas maybe with lifting leg to go up the stairs or during terminal stance when on full stretch; or if quad then maybe it’s the concentric portion of the squat or eccentric lowering down steps
– Would want to ask about history of any low back pain or any current low back pain to help differentiate lumbar vs hip pathology

4) With negative lumbar screen, neuro exam, and neurodynamic testing, and positive hip intra-articular testing, range of motion losses in all planes, and noted gait deviations it seems to be in line with my primary hypothesis if hip OA; to further rule this in hip accessory motion testing would be useful to perform

5) Depending on severity and stage of OA, irritability, and patient goals I feel like my first line of defense would be lateral distraction with a belt more so for pain alleviation

[awilson12]

I think that with such a narrow population (majority looking at McKenzie and low back pain) it is hard to generalize the poor quality, limited evidence that this systematic review based their conclusions on. I still think that symptom modification serves as a good educational tool and guide for areas of treatment, but hanging your hat on that shouldn’t be and can’t be the end of what we do. I feel like it is an oversimplification to base treatment solely off of symptom alleviation without regard for other objective and subjective measures that are also helping us to gauge effectiveness.

I will admit, easier said than done, though, because so many people just want pain reduction and this can be a low hanging fruit to assess and re-assess. I agree that there likely needs to be more evidence on this and we probably aren’t as good as we think we are. Just goes to show the importance of 1) specificity in treatment, 2) ensuring we are making things functional to help with long-term carryover, and 3) educating on improvements in other outcomes besides subjective reports of pain and disability.

For me this is a good reminder to be better about choosing what I am using for test-treat-reassess and education on this.

[awilson12]

I think that in general it can be easy to take studies (no matter how well done) and find something that you see as a flaw in clinical applicability and remain closed minded on changing practice patterns, which could for sure lead to inefficiency in patient care. Not being open minded or efficient enough in clinical reasoning to change your plan of care if you aren’t getting the results you expected is something that I find myself doing too much. This study is a good one to challenge practice patterns in this population, but also make me think more about other areas where I might be trying to force what I think is the right treatment but need to do more research.

In particular have been struggling with a few patients with knee OA and have been doing some more digging. Anybody have any good articles for treatment in this population they can send my way?

[awilson12]

Lauren- yeah that’s true… may be another thing to consider when weighing this article into clinical reasoning on what patient characteristics to look for for those who might better benefit from this treatment.

[awilson12]

Taylor- Good points to think about! I had the same thought for sure of well they did have a reduction in pain with PT, but if it was no more than a passive modality then what role do we need to play in this situation and is it something we can still justify as skilled care? I still think yes, but, like you and Steve said, it might be more/just as important to focus on education and communication.

Maybe I just didn’t dive deep enough into the data, but when reading the study I struggled with identifying specific characteristics of the subjects that might help us as clinicians identify which patient might benefit from more “extensive” PT vs something more hands off like you alluded to. Only thing I really came up with is that about 50% of the subjects were classified as grade 2 on the radiographic severity scale, so maybe we can provide greater benefit to those in the mild stage? Feel like that requires some more digging in the research to back up though.
Anything jump out to you or anyone else?

[awilson12]

Agreed- very well done study.

Met just about everything on the PEDro scale: RCT, patients and assessors blinded, concealed allocation, specified inclusion & exclusion criteria, between group analysis, similar baseline characteristics between groups, outcome measures obtained from all at baseline and >85% at 13 weeks, included treatment effects and “measures of variability”

Other methodological strengths- robust inclusion of valid & reliable outcome measures, power analysis, long term follow up, large sample size

Correlates to clinical application- started with increased frequency of treatment and decreased as progressed, manual treatments and exercises in line with standard of care and (somewhat) patient specific, included subjective and objective outcome measures to track progress

I found it interesting that the active treatment group had higher percentage of people that correctly identified their group compared to a relatively low percentage of people in the sham group. Gives good insight as to the power of belief in treatment seeing that there were fairly similar reductions in pain and improvements in function between groups.

I think that just because there was no difference between the groups that we still don’t have something to offer these people- they did find a reduction in pain and improvement in function with PT. While they did provide interventions similar to PT practice patterns, looking at the specific interventions and percentage of time they were used identifies a few exercises and manual therapy techniques that were used >50% of the time. Was this done out of ease, specific patient presentation, PT preference? Obviously we don’t have the answer to this question but I feel like this is where clinical reasoning comes in to make sure that treatment is individualized to each patient in hopes for improved outcomes.

[awilson12]

1) Primary and top 3 differentials:
– Primary hypothesis: L4 radiculopathy
– Differential diagnosis: mid lumbar facet arthropathy, lumbar multifidus referral, peripheral nerve entrapment- femoral/saphenous

2) Doesn’t completely fit expected clinical pattern but most consistent with L3-4 radiculopathy
o Asterisks: subjective report of n/t and weakness, myotomal, dermatomal, and reflex changes in L3-4 nerve root distribution
o Inconsistent findings: no aggravation/alleviation with lumbar range of motion (with initial aggravating factors seemed more extension sensitive so would expect this to change symptoms), negative SLR

3) Lumbar quadrants, sustained and repeated motions; interested in quality of lumbar AROM screen

4) With no specific provocation during the exam, it is difficult to identify original contributing factors to LE symptoms; that being said I don’t think that PT is an inappropriate place for this patient and because of current decreased irritability can probably progress faster to return to function

[awilson12]

Learning about motor learning in neuro class was interesting but always something I have struggled to find how to implement- it’s easier to just tell someone what to do than figure out a different way to get them to change their motor pattern for the desired outcome. Had actually just read this article earlier this week, and found it helpful as a reminder of these principles and to give some more specific examples of clinical application in this population that can also be used for every other patient to some degree.

Take home points:
– external cuing, meaningful and patient specific exercises and verbal cues/analogies, variability in practice order and environment/situation may further increase adaptation of movement patterns with improved carryover
– self-controlled learning is something I haven’t really thought about outside of the pediatric setting; makes sense to increase engagement and motivation for positive experiences to potentially enhance motor learning
– I need to challenge myself more to 1) implement these strategies and 2) identify appropriate times to progress feedback in this manor

[awilson12]

Agreed with Eric. It seems like there may be some sort of lower level evidence to support this, and I would argue pain and range of motion are definitely desirable outcomes and potentially easier and more reliable to measure in the clinic vs swelling specifically. One of my CI’s used this on occasion for post-op TKA when swelling was really limiting progression of range of motion and strength, and he had some good success with post-treatment range of motion improvements.

[awilson12]

Kind of going off the lymphatic drainage point… Swelling is definitely something I have kind of neglected placing an importance on managing, but more recently have realized how much it makes a difference (especially for ext ROM and strength). I am not sure from an evidence based standpoint what the recommendation is for frequency of elevation, but I have been trying to do a better job at telling my patients they should try and elevate as much as possible immediately post-op and for 10-15 minutes every couple of hours if possible once they are a little further out. Thoughts or suggestions on this?

In terms of HEP- early on I feel like its a given that these lower level exercises need to be performed every day. Where I am unsure of frequency is later on when you are really able to challenge strength and stability to a greater degree. I guess my concern is that every day may be a bit much and lead to potential overuse injuries, so I have been experimenting with A day and B day type routines with off days to add some variability in focus. I just struggle between not wanting to under dose or over dose. Thoughts on this? What is your education like on what to do, how often, soreness, etc. during the mid to later stages?

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