[awilson12]

Yes, for sure need to go over this! Thanks for the input. I definitely struggle with variation in my manual techniques from patient to patient and as one technique is no longer giving me the same benefit, so a posterior tibial mob with facilitation of extension distally is something new to give a shot.

[awilson12]

From just comparing the folks I have now, I feel like I have a few characteristics that moving forward I can use to help gauge accelerating or delaying rehab:
– involvement of other ligament or meniscus repairs usually come with range of motion limitations and weight bearing precautions for a certain period of time, so respecting the surgeons protocol is one indication for delaying rehab; also from a clinical reasoning standpoint need to have an idea of what stresses these structures and may have to delay progression because of healing timeframe and the tissue’s ability to handle increased stress
– pre-surgery strength and range of motion: I have a guy in his 30s who has been a “coper” for years now until another injury mountain biking led him down the surgical pathway; I have found I am able to progress him much quicker because he had full return of strength and function prior to surgery, and was a highly active and strong dude all the way leading up to surgery; post-op day 1 he had the best quad contraction I had seen in this circumstance and I have been to progress him much quicker than any of my other post-op ACL-R patients
– patient affect: again going back to a specific patient example I have a teenager who on paper seems to be a good candidate for “accelerated” rehab (ACL-R only, good range of motion, good quad contraction early on, good overall fitness), but in some instances haven’t been able to progress as quickly because of his fear and lack of confidence in his abilities
– post-op “complications”: one of my patients had a meniscal repair as well as ACL-R so was limited from that standpoint, but even after the period of precautions she is an example of “delayed” rehab; gaining extension back has been a struggle for sure (likely part my inexperience but also HEP compliance) and this has in turn delayed strengthening, which is likely going to affect the overall time frame of return to higher level activities
– goals: if a patient is in no rush to get back to high level activities, then there might not be a need for progressing as quickly

Would love to hear others thoughts on this!

[awilson12]

Some follow up on another resource- listened to a really awesome and interesting podcast today on my run that really challenges a lot of common PT practice with ACL rehab (or just in general) and provided some cool ideas of things to try in the clinic.
Complete Football Health Podcast: Neuroscience and Knee Injuries with Dustin Grooms

[awilson12]

Great resources and well worth the few minutes to take a look at and think about.

From the slinky video a few specific quotes stood out to me 1) “scientific research has shown that if you don’t make a prediction, what you learned from [this] will be no more than if you never saw [this] at all” and 2) “sometimes you need to know what is there, what you are actually looking for, before you see it.”

Some of my take home points from the reading prediction video:
– Prediction allows us to think ahead about what may occur and also create our own ideas; it increases our engagement
– Prediction before- based on current information/presentation and prior knowledge
– Prediction during- reflection on what has happened and predict what will happen based on this
– Prediction afterwards- reflection at the end to check the accuracy of your original prediction and evolution of your prediction
– Confirm your predictions based on what you already know to help comprehend what is going to happen

Primary hypothesis and differential diagnoses could just as easily be called predictions. Clinical practice is all about making predictions, challenging your predictions throughout, and reflecting during and after patient encounters to see if your prediction was right and/or how it was different or the same from what you expected. These concepts for sure tie into the formative assignments, clinical reasoning form, and discussions during mentorship time. All of these things help to be a critical thinker before, during, and after, and through using this process enhance learning from these situations. The second quote I mentioned from the slinky video also makes me think of clinical pattern recognition and how you need some sort of framework to make sense of findings in order to them to be relevant to you.

[awilson12]

2) Definitely some good additional differentials to think about
a. I didn’t include cervical radi b/c I felt like the symptoms and aggravating factors didn’t sound neurogenic in nature to me; however, I think with there being neck pain and distal symptoms cervical radic would have been a good addition
b. Steve- that may be a good point of WAD being more of a overarching term (like chronic low back pain or patellofemoral pain syndrome) vs a specific diagnosis; my line of thought in including that is that in this situation there might not be one consistent driving factor due to the circumstances of the event and over the first couple of visits as irritability decreased I was able to more specifically rule in and out different things to hone in on more specifics of what was going on

THOUGHTS FROM THE REST OF YOU ON WAD BEING A DIAGNOSIS?

c. Helen and Lauren- after subjective cervical was definitely higher on my list than how I have it listed (retrospectively writing the case up I just put down differentials & was biased by what I already knew so I didn’t really order them specifically how I had them ranked after my subjective so that’s my bad)
d. Helen- in terms of ligamentous laxity it was something that I looked at during my objective so definitely appropriate to have on my differential list; they did pretty comprehensive imaging but still something to keep on the radar with trauma involved

3) I choose mod-severe irritability after subjective b/c the thoracic region pain was constant, seemed easily aggravated, and when it got really bad could lead to severe pain for 1-2 days; shoulder and neck were less irritable and took longer to get to the point of lasting symptoms for a few hours –> throughout the exam she tolerated AROM well but after this point started to report steady increase in symptoms
a. Day 1: only mid cervical AROM- all straight planes and front quadrants (not sure why I didn’t do back quadrants or if I just didn’t remember to document this), shoulder AROM (flex, abd, ext, ER & IR at 0), ER/IR resisted testing, palpation
b. Agreed, with this information it is definitely difficulty to determine disc vs myofascial; I did not do compression testing or attempt to unweight myofascial structures which I feel like with the tests I was already doing would have been something worthwhile to throw in without adding too much to aggravate symptoms
c. Brandon- all other cervical range of motion created slight neck discomfort but there was no specific reproduction of multiple areas of symptoms like with front L quadrant; L rotation, SB, and flexion were limited more so than other cervical movements but slow and guarded for all directions (did not do a great job at quantifying any of them specifically)

4) Barrett- I forgot to add on there that day 2 I did upper cervical UPAs to follow up upper cervical screen and headache was reproduced with R C1-2 UPA

[awilson12]

Thanks guys! All good questions and points to consider.

Response to first question-
a. Agreed, NDI could have been another outcome measure I could have administered (the front office staff gives them out based on body region and her referral was for shoulder). I was also thinking along the lines of impact of events scale or FABQ that could have provided some good information.
b. More information on the MVA- she was the only one in the car and was stopped at a light and someone hit her on the driver’s side going about 30-40mph; she had immediate onset of global pain and was taken by ambulance to the ED where she got imaging (CT of chest, head, and neck; XR of chest, shoulder, and spine; later got MRI of shoulder)
c. Mentality after MVA- no litigation, insurance taking care of car and medical bills; generally frustrated at not being able to work and do every day things
d. Progression of symptoms since accident- got better over 3 week period of not working, went back to light duty and got progressively worse over 2 weeks leading up to seeing me
e. Light work duty- she had been on light duty for 2 weeks at this point; as much as possible she wasn’t having to help with patient transfers, hanging IV bags, and was allowed more rest breaks, but due to the nature of the job she sometimes had to do more than she would have liked
f. Sleep disturbances- unsure about which side she usually sleeps and sleep was disturbed but wish I had more information to give you than this in terms of how often, how long she was awake, etc. so definitely a good line of questions to store away for future use
g. Medication- only takes muscle relaxer before bed b/c made her sleepy/groggy; not on any opiods at this point b/c doesn’t like how it makes her feel; on prescription NSAIDs and taking every few hours as prescribed; unsure the time frame of taking meds and coming to PT; good point about asking more (especially at this point being a few visits in) about how often she is taking them since progressing in PT and gauge her feeling on decreasing utilization
h. Headaches- definitely could have been more specific in querying about headaches; all I know is that they were R sided and she has had them just about every day since the accident
i. No prior history of headaches, neck, or shoulder pain; did not present with any concussive symptoms and denies any following the accident
j. Regions of pain- thoracic region pain was severe and constant and increased with shoulder movement > neck movement; shoulder/chest pain was reproduced with shoulder movement (especially more quick movements or reaching overhead) and relieved by rest; neck pain was reproduced with neck movement and slightly with shoulder movement but was less than other regions

[awilson12]

Don’t think there is such thing as a perfect evaluation just about ever!

Feel free to defer any question if it is already a part of your discussion for Saturday, but just a few things I was curious about-

Did all of the areas have the same aggravating and easing factors and could you/did you establish the relationship between all of them? Was there anything in particular that for sure aggravated all of the symptoms?

You mentioned irritability was min-mod, could you elaborate on this?

You touched on PAM being non-painful and AP “feeling good”; were there any limitations there?

There were areas that were TTP but did any of them specifically reproduce this patients pain?

[awilson12]

Working hypothesis and differential diagnosis:
a.) What is your working hypothesis regarding this patient?
– labral tear with cervicothoracic myofascial involvement (upper trap and paraspinals)
b.) What are your next 2-3 differentials? (Ranking order)
– Mid-cervical disc pathology
– RTC tendinopathy/tear

Special testing:
a.) What are your thoughts regarding the special testing chosen for this patient?
– It was a bit all over the place but can see where you are trying to bring in various tests to help rule in and rule out differentials
b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?
– With potential labral pathology looming and a traction mechanism of injury (I think… might just be visualizing the injury incorrectly) another labral test to consider adding is biceps load II

Clinical Pattern:
a.) Does this patient’s presentation fit a clinical pattern?
– I don’t feel like there is a very clear clinical pattern for just one area of involvement; seems more like there is a mixed bag of shoulder and cervical/myofascial
b.) Briefly, what are your thoughts regarding his headache?
– I would want to know more information (i.e. location and aggravating factors) and if that presentation is in line with objective findings

Evolution of Patient’s Symptoms:
a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.
– He potentially could have had an underlying shoulder and/or neck pathology that predisposed him to a specific MOI
b.) Are there any red flags?
– doesn’t seem like it

Treatment:
What Manual therapy and HEP would you give the patient on the first day?
– manual: scapular mobilization because of pain alleviation with scapular assist test, STM
– HEP: row with (B) ER and prone scapular retraction (“I’s”) to facilitate lower trap activation

[awilson12]

Moral of the story- thoughts about thinking about your pain makes you think more about your pain which makes you think more about how bad your pain is which makes you have more pain which makes you continue to think thoughts about your pain…

On a more serious note, though, reading these articles and learning more about pain metacognition was pretty cool. I can’t say I have really thought much about this before and definitely haven’t thought about the differentiation of positive and negative metacognition.

Recently I have had some tricky patients that fit into the patterns these studies talk about. I have tried to incorporate more reflective questioning to get insight to their thoughts on pain and also try and open up a doorway for further discussion. I have about a 500 record with this and have found that continuing to change my questioning and explanation until it is something they really relate to and understand, and then just harping on that.

This tool, although mentioned that it is not yet been tested to determine outcomes of MCT, is something that I could use to understand to a greater degree their thoughts and biases and begin to “break down” their misconceptions.

[awilson12]

I too am a podcast person for long runs and drives, so I am always looking for good PT related ones as well! Helen- I will have to check out the ones you suggested.

I have listened to a few PT Inquest ones and they have been pretty good. Like Taylor says the first 15-ish minutes is kind of just random Q&A/chit-chat, so I tend to just fast forward through that part.

Recently I listened to an episode of runchatlive podcast on Running Injury Assessment. That one in particular wasn’t all that great, but I am going to check out some of their other ones to see if they are better. This podcast isn’t a PT specific one though, so I’m not sure yet how applicable everything is to us.

I follow Kettlebellphysio on Insta and they post a lot of suggestions on various podcasts and new research articles to check out. I also follow a PT (dr.nicolept) who posts a lot about rehab for soccer players and have listened to a few episodes of her podcast series (complete football health podcast) and they are pretty good. She also posts good ideas for progressive therex for treating soccer players and I personally have found some of the ones that are focused on ACL rehab helpful.

[awilson12]

Definitely a great review for anatomy of the forearm and hand.

One area that could have been more specifically broken down due to his previous shoulder injury was rotator cuff referral, so quickly adding in some resisted testing for ruling that out could have been something that was also done. Overall I feel like they did a good job with differential diagnosis and describing their thought process with ruling out, as well as addressing areas they might not have thought about initially in the discussion.

Treatment wise adding strengthening of the entire upper quarter was a good place to go, especially with a previous shoulder injury that potentially could have contributed to overuse in this area with the increase in activity. Also incorporating trunk and lower extremity mechanics into functional movements to decrease UE strain could also be another place to look at.

[awilson12]

Thanks for the post! Definitely helpful to see a case spelled out to think about what I might expect and things to look at before I am thrown in the hot seat when I have this diagnosis. Also the articles provide some good guidance for examination and treatment.

Kind of going off what Helen and Brandon hit on… with there traditionally being a high likelihood of a cervical component along with TMD, what exact cervical screening did you do? Did you do quadrants, compression, or specific OA and AA differentiation tests? Definitely seems like TMJ is involved from your findings, but could just help identify another area of treatment if you didn’t already do as provocative cervical spine tests in your eval.

What method did you use to quantify TMJ range of motion?

From my (limited) understanding I think I remember learning that with a C curve it deviates to the side of the hypomobility? So if its convex to the left then that would mean R was more hypomobile?
Evaluation wise were you able to identify specific TM joint restrictions that guided your treatment in addition to range of motion loss? What did you use as your test-treat-reassess asterisk for TM joint mobilization?

[awilson12]

1) I think that their methods and results they stated are in line with their conclusion that mobilization + “routine” PT is better than just “routine” PT. The outcome measures they used seemed to be appropriate to measure what they wanted to.

2) I am always interested at how various studies define “routine” therapy, and feel like the definition is never actually what would be done in the clinic… I hope. I can see from a study design standpoint that having a more passive “active” treatment would potentially lead to easier comparison and determination of the effects of mobilization compared to if they performed some other manual technique as a part of routine PT. Adding in some sort of other cervical technique (ROM, STM, etc.) could potentially be more variability in treatment received compared to ultrasound, thermal therapy, or TENS. I think in this situation you just have to take the evidence with the understanding of this limitation and that research design to control for variables and increase internal validity is difficult.
Aside from that dosing mobilizations based on patient presentation is in line with what you would do in the clinic, so that was a strong point of the study in that respect.

3) One limitation to the study is that there was no long term follow up. It would be interesting to see any changes in the effect in the long term. I feel like the exclusion criteria also may have excluded the type of patients that would come into clinic- I would argue it is rarely just mechanical neck pain with no other contributions. Not necessarily a limitation in research design, but I feel like they kind of got away from their focus with the discussion and kind of brought in various topics that weren’t addressed previously or super relevant to discuss.

4) I would say it took me about 45 minutes to read and critically analyze the article in terms of limitations, strengths, benefits, applicability, and validity of the study. Personally this is always where I struggle with research- I have so many questions but my efficiency of searching and reading is a big limiting factor in being able to look up everything that I have questions about. Another thing that I have a hard time with is determining applicability in clinic when my patient doesn’t exactly fit the population, or to what degree I can use the methods in a way that is reasonable in clinic.

[awilson12]

1. What are your top three diagnoses based on the subjective information? (ranking order)
– cervicogenic HA (upper cervical facet referral)
– muscular referral- upper trap
– mid cervical disc/facet

2. Using your number one differential, what would you expect to be (+) during the objective exam to support your hypothesis?
limited and painful left rotation, (+) CFRT, HA reproduction with C1-2 UPA

3. What is your top diagnosis based on the objective information and why (asterisk signs/symptoms)?
I feel like there are two things that contribute to this patients symptoms:
1) CGH because (+) CFRT and pain with LC1-2 UPA
2) lower cervical facet dysfunction (C5-7) because pain and limitations with SB, rotation, and extension, and pain reproduction with C5-7 CPA

4. What Manual therapy and HEP would you give the patient on the first day?
I would either choose upper cervical or mid/lower cervical to address first and then assess efficacy of that treatment before adding in other techniques; so for starters lets say I will go with upper cervical
manual- upper cervical UPA Gr II-III for symptom alleviation and mobility (low irritability but can progress or regress based on tolerance)
HEP- C1-2 SNAGs

5. Is there something that doesn’t sit well with you in either subjective or objective? If so, what other subjective questions and objective tests would have been helpful regarding this patient case?
I would like to know more about PMH as some non-msk differentials were lower on my list; with muscular referral being on my differential list I would want to add in palpation to rule in or out myofascial contribution; even though the patient presented with bilateral neck pain UPAs at levels that reproduced comparable pain might give some good information in terms of mobility and pain for some insight into treating

[awilson12]

Kyle- I think for sure that talking about something the patient relates to makes our education more effective. From a scientific standpoint the connections between emotion & memory definitely points to this and something that is more meaningful to you is going to “stick.” Understanding of medical terminology is for sure situational dependent, but I would argue that even those who have a better understanding likely have some misconceptions as well.

A good take away from thinking about making education relatable is that you have to get a good grasp on the patients understanding, beliefs, goals, etc. in order to decide what you should/can talk about day 1, what might need to be chipped away at or addressed further down the line, and what delivery method is going to work for them. Easier said than done though with so much to think about during an initial eval.

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