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Hi everyone. I think my biggest question and topic I wanted to bring up is where do we think this person lies on the biopsychosocial aspect of things? It’s obvious that this needs to be addressed but I wonder how much and its implications for her plan of care? I feel like I’d go down this road hard, but I don’t necessarily know if that is most appropriate. Erik (if I am going to assume) would maybe do mostly education? Cam nation maybe a little less?! Jeff, I’m curious as how much of those yellow flags were noted via just general questioning or did you intentionally spend time on these topics trying to get a better understanding of her beliefs and overall biopsychosocial status? Did you feel good about the information you got from her? Where would you classify her psychosocial risk status (low, medium, high)? How much of ths played into how you conducted your examination and eventually treatment/POC? (sorry for all the questions)
The reason I bring this up is after reading this article: Listening is therapy: Patient interviewing from a pain science perspective (Physiotherapy theory and practice, 2016) It made me wonder if I read this prior to evaluating a patient like yours would it have changed the way my interview, examination, and treatment? The paper discusses the importance of screening those yellow flags, identifying those psychosocial barriers, and how steering your examination and treatment should be highly driven by your subjective from a pain science/education standpoint.
Hi guys, continuing this train on treating plantar heel pain. Here’s the second article: “Effectiveness of Trigger Point Dry Needling for Plantar Heel Pain: A Randomized Controlled Trial.” Have a read. 😊 I’ve listed some questions below to help drive the discussion, however I encourage you to come up with your questions as well!
-Has anyone had exposure to this treatment for plantar fascitis? Have you seen success with it? If not, what clinical application do you take away from this article?
-What clinical and biopsychosocial factors would drive your reasoning process on choosing dry needling as a treatment technique?
-Do the limitations of this study, both discussed in the article and flaws you may have identified yourself effect your opinion on the conclusion of this study?
Interesting that you all bring up this idea of stretching versus strengthening when treating plantar fascitis. I was listening to a podcast the other day where they were discussing this exact thing. They were emphasizing the need to meet these patients where they are along the continuum of their pain, treating pragmatically. Obviously managing them in the acute stage, strengthening may not be well tolerated and neither may a firm orthotic that is just prodding away at the irritable tissue. I think exploring less invasive changes to decrease tissue load to the plantar fascia should start with education on shoewear then thinking of adding adjunct treatments like taping, then on to more invasive/expensive orthotic options. I’ve also found that a lot of these patients might already know what has worked and what hasn’t (through their attempt to self treat) so digging into what they have found helps or doesn’t help during the subjective history is very beneficial as a clinician to know where my recommendations might lie on that spectrum.
Going back to strength versus stretching…..Take a look at this study by Rathleff published in the Scandinavian Journal of Medicine and Science in Sports (2014) that compared plantar-specific stretching with a heel cup vs high-load strength training with a heel cup. The results found that the high load strengthening group was associated with a larger improvement in FFI (foot function index) and tendency to be more satisfied with the results of the treatment compared to the stretching group. Interested to see what you guys think about it?
1. Nothing really new to add here.
2. I probably would have probed more into looking at his aggravating factors and the onset a little more like Erik was alluding to. Based on how much this guy is pushing he obviously wasn’t able to do this overnight so was there a new training regimen whether it be in the gym or at work? Possibly asking more about his hobbies and if there was a recent change whether it be intensity/frequency of an activity, gun type/posturing, seeing if there is something setting him up for failure to pump iron like he normally does? Just a thought.
3. Nothing new to say here. Agree.
4. Order seems logical and sound. I definitely agree with your choice to do it day 1, its his c/c so buy in points right there. Like Jeff said I think knowing where his deficits lie by performing the objective test and measures first would be helpful to understand where the weak link might lie and to facilitate cueing with his bench form. Because I have little new information to add, I am going to be devils advocate here. I just wonder how much of our typical PT objective data and assessment would directly translate into benching 275 pounds or his “push days”? Would it make us more specific with our education or cueing for this activity? If you screened for red flags, cleared cervical spine, and narrowed down the aggravating MOI to weightlifting could you have started with functional testing to drive your assessment? Most of those shoulder tests are sensitive anyway and he likely might have concomitant pathology so how much does it matter knowing this day 1 versus FU visits? I don’t think I would have done it any differently then you did Jon but I do wonder. Regardless, doing it day one…. I applaud.
Jon your earlier post said: “He wasn’t training the posterior chain or back muscles appropriately and was suffering from it. As a result, his scapular mechanics were wonky and his lack of motor control of the middle/lower trap showed.” How much of that would you have gotten if you went through his workout routine “functional testing” versus the rest of your exam?
5. I think as far as day 1 I think activity modification and education would be my go to!
Hi all!
There was one line from the results section that stuck out to me that I wanted to bring up in this discussion board: “Treatment credibility ratings after the first treatment sessions were significantly higher in the active group than in the sham treatment group, indicating greater participant confidence in his/her treatment and its effectiveness but were not different after the last session”. Anybody else wonder why that would be? It had me questioning what about the subsequent visits that lost the patients confidence and effectiveness?
I would consider that it may be because the physical therapist was evaluating, assessing, and educating them on their specific physical impairments like joint and soft tissue restrictions and relating these finding to their pain and/or functional mobility. If their confidence in their treatment and its effectiveness continued with treatment sessions less driven by physical impairments (PT goals) but by addressing their participation restrictions and functional limitations specific to them would the outcomes have been the same?
This study used a multimodal approach (“semi-standardized” aka as semi cookie cutter) with the active group interventions being sound clinical and pragmatic plans of care for patients with hip OA. It could possible that the active group intervention just missed the mark on where their emphasize should lie when providing individualized care?
I’d like to think that if visits weren’t about getting more hip extension, but about using interventions and treatments to then reinforce its usefulness with a patient specific goal, like getting down on the ground to play with their grandkids or to garden results may have tipped in favor of the active group. We as physical therapist need to maximize the benefits of physical therapy through a patient-centered approach to be more effective with emphasize on communication and treatments geared towards specific tasks required to achieve treatment goals.
But again I am young enthusiastic PT so what do I know! #pumpuptheplacebo
Jeff- To answer your question, my guess would be because its a syndrome and a diagnosis of exclusion, like you pointed out, they are stressing the emphasize on the neurological exam to screen out for more serious pathology with objective measures. I think they want us to ask ourselves do we have enough information to treat this patient and using a neuro exam with the addition of using highly sensitive tests should be carried out during the evaluation process. And your question of do they do this on every patient? I would say its definitely a possibility. One of my previous CI’s did a neurological exam on every patient she evaluated, she felt it was important to always be suspicious of neurological dysfunction. She followed Naber’s orthopedic examination process, which in his work he stresses that the “neurological examination has the greatest significance on treatment planning”.
I currently am treating a young man who has a history of athletic pubalgia, who I evaluated about 8 weeks ago after getting a “core muscle repair” or sports hernia repair. He had bilateral rectus abdominis, adductor longus/brevis and pectineus compartment decompression and repairs. This is a surgery I have never seen or treated before so this article has assisted me in progressing his rehab appropriately which has been rather challenging for me. The protocol that was sent to me via the Vincera Institue in PA, where he had his surgery, is rather aggressive allowing the patient to initiate running 8 days post-op. The patients protocol also indicates agility, plyometrics and sport specific activities being incorporated at week 3. Does anyone else find that surprising, because I sure did?
This article has been and is going to be helpful for me to progress this patient appropriately using the different stages of intervention starting with Stage I: addressing pain control, motion, and strength and stability, to then progress to the stage addressing the regional interdependence (stage II) to stage III which is much more sport specific. I like having these guidelines instead of this trash protocol given to me because it addresses the need for a restoration stage, appropriate tendon loading and allows me to use it as a means to educate my patient why we are progressing slower then what is indicated on his rehab protocol.
I also think this article does a great job of highlighting the importance of regional interdependence, which is where I feel my patients impairments current lie and are requiring a more conservative progression. This patient has had bilateral lower leg fasciotomies (4 compartments) and strayer procedures 2 years ago and has had compensatory patterns with his ADL and sport activities for years. This article has heightened my awareness of why I need to step back and get a bigger picture of the kinetic chain as we progress, because its clear (at least to me) that the forces applied distally have had a impact to the proximal structures which may have led to this surgery. The suggested exercises will be very helpful for me to prescribe appropriately knowing where his deficits lie and knowing I need to educate and incorporate appropriate rest in order to assess response to tendon loading.
There is also a really interesting podcast on clinical edge: https://www.clinicaledge.co/podcast episode 85 which is called “How to rehab groin and lower abdominal pain in running and gym junkies with Andrew Wallis”
I agree, two great articles. I the gluteal tendinopathy article has helped me so much be more efficient and effective with my differential diagnosis. I also really love the visuals that are provided. I have used those exact pictures to show my patients for patient education. Commenting on Jon’s post of not thinking of isometrics for gluteal tendinopathy had not occurred to me. I actually have a patient with a pretty irritable and severe gluteal tendinopathy and I was thinking any activation of that muscle was going to make her hate me and never come back. I have her the supine isometric hip abduction with the thigh supported and she absolutely loved this exercise! This is when I decided to bring up this article and show her the varying degrees of compression based on position. Found myself another highly visual learning, I felt like this helped more than anything I was going to do or teach her. Total light bulb moment for her!
The second article is also very helpful for therex prescription. It really highlights to me the importance and finesse to prescription if done correctly. For example, with my patient I described above with gluteal tendinopathy and potentially a gluteal tear, I want to find the most appropriate exercise to improve her glut max strength while minimize the amount of compression and tensile load on the gluteal tendons all the while trying to make it functional as possible. We have been doing mini squats however once irritability improves, I was wondering where I would progress with her exercises, especially since she doesn’t tolerate side-lying or even quadruped on elbows stabilizing with her involved LE for glute max strengthening. This article will help me immensely to prescribe appropriately going forward. Finding that sweet spot of highest Gmax activation while minimizing the amount of tensile load on Gmed will be my biggest challenge. I think retro step ups are in this lady’s future. Reiman’s EMG study will definitely give me a nice linear progression and resource to draw from for therapeutic exercises to load the tissues/tendons appropriately while respecting the amount of tension/compression of the tendon that has been driving her lateral hip pain. Oh and by the way, this lady was clamshelled to death prior to coming to PT if anyone cared. Really rocking the PT community with taking away the clamshells heal all mantra!
Hey all. I don’t really have much to add however reading through this discussion chain it reminded me of a conversation I was having with one of my patients who recently was seeking my opinion on conservative versus surgery for a SLAP tear. By the way, this guy should not get surgery.
I won’t bore you with all the details of his injury etc. however after giving my professional opinion (lets try PT first), he hit me with a question that kind of stumped me. His question was along the lines of “So are you telling me I’m going to have to do all these exercises and stretches for the rest of my life to feel better in order to get to where I want to be with my shoulder and do what I want to do?” making other comments like “if I get surgery it sounds like more work up front but less work in the long run”
I realize without a lot of detail it is hard to give me super specific advice on what to say but wondering if anyone has had similar interactions or discussions with their patients? Cam, what would you say to this guy if he had similar questions about his knee. For example, maybe after his therapy session with his exercises he feels and moves better but to him that’s an hour out of his day he is dedicating to his knee. Relaying the “first line therapy” idea to the patient with evidence, like this article, is great to have however what I hadn’t thought about is what are these conservative people at 24 months follow-up still doing regarding their HEP? Are they still dedicating a lot of their time to their exercises versus those who had surgery and are 2 years out. I wish I had better insight or experience to better communicate with my patients on what their management will need to be in the long run with conservative management. Just some food for thought.
Hi Katie,
Wondering how much you have looked into his L hip? Things that jumped out to me where the swing test, antalgic gait, axial load trauma injury while in a knee flexed position wondering what your thoughts are on that? What does his hip ROM look like? Wondering if there is a possibility of hip instability and irritation to the neural structures?
Hey Cam,
Wondering if you’ve thought of assessing GH stability with this patient? After your presentation, it reminded me of one of my patients who has a very unstable shoulder joint with little tone, for reasons I won’t go into, but he presents with similar upper trapezius and lateral arm pain. Especially since your patients complaints are working at a computer and at microscope with his R arm unsupported (sustained traction) for prolonged periods. Just something to think about as a possible contributor or chronic MOI (if that’s a thing)? Just a thought!
Erik you are so right! Young kids are pretty lousy at expressing themselves when it comes to explaining their pain or describing their symptoms. I’ve also found it just as difficult sometimes to get certain student athletes to buy-in to get them to understand why they should, need and want to be there. Because face it, most of the time they are there because their parents are making them. If this is the case, which sometimes its not, I have a hard time convincing myself whatever we do in therapy will translate over into their day to day life if they don’t understand how this has any correlation to playing soccer, going up to make a lay-up, or whatever the case may be. I think more than ever this is where we can set ourselves apart from other healthcare providers by providing that patient-centered intervention guided by function. I have been trying to correlate my therex and other interventions with things they can relate to whether it be side stepping with a basketball in their hand, SL balance on foam while kicking a soccer ball against the wall, or breaking their tasks into parts so they can at least see how it relates to what they want to do. I’ve found that to be really helpful for me to take away some of the medical jargon I tend to want to throw at people and get them to talk to me about what is hard for them to do in their sport. I have also been trying to give them specific tasks that I want them to be able to do when they come back, making it very goal oriented. For example, “I want you to be able to rock out 15 of these SLR at the beginning of next visit.” Kids like to win so I try and use that to my advantage a lot of the time when it comes to getting them to do their exercises. I think sometimes I take on a personal goal to get them to care more than they actually do and maybe that’s a waste of effort on my part but hey, you live and you learn. Anyone else have any good suggestions or thoughts on this?
Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
In addition to what other people have said based on prognostic factors of chronicity:
-I may want to give the hyperarousal subscale. It comprises of five items that evaluate the frequency of symptoms including: having trouble falling asleep, feelings of irritability, difficulty concentrating, being overly alert, and being easily startled. This could help with driving my decision making based on prognosis
– Inquire about headache at inception of accident
– Preinjury neck pain
– Inquire about low back pain at inception of accident
-Sensitivity to cold
– Concussion questions? Did she have one? What were he symptoms directly after the accident? Was she followed by Neurologist?5) What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
Based on the fact this patient has minimal irritability “immediate resolution of symptoms with cessation of aggravating activity” I think postural education and educating her on this will be huge. Less aggravating activity less pain.I also may also print off this integrated biopsychosocial model describing potential mechanisms for the onset and maintenance of persistent pain and disability following acute trauma. And discuss her presentation and how it applies to this cycle of chronic pain. https://www.jospt.org/doi/pdf/10.2519/jospt.2017.7455
Bunketorp et al., found that self-efficacy, a measure of how well an individual believes he can perform a task or specific behavior and emotional reaction in stressful situations, was the most important predictor of persistent disability in those patients.
May want to think about a multi-disciplinary team for this patient. Behavior, pain and cognitive therapy options.
Sorry its me again!
After reading the systematic review I realized that 11/12 identified codes within the 4 themes were based on good verbal and patient interactive skills. Not only does this data not surprise me it makes me re-evaluate how much of my own patient communication I can improve on. I sought out this residency knowing I wanted to enhance my skills regarding my technical ability and skills (under theme 2). Which I am happy to see my investment is going towards good use and will help me improve my patient interactions. However, what I didn’t understand is how much I have to learn and the vast growth I can gain in my verbal communication skills.
After a recent mentoring time with a highly irritable and hypersensitive patient with chronic low back and hip pain I have never been so appreciative of these themes. This patient was struggling in many areas of her life. Her medical history form was extensive however very suggestive of someone was dealing with a hypersensitive system, from GI issues, sleep disturbances, depression, and muscle aches and pains. Upon our patient interview, patient reported her hesitancy of coming to physical therapy due to her skepticism of what could be done to help her. Based on her state of hypersensitive state I was so nervous how to proceed with my objective portion of my evaluation. I was weighing in my head what tests can I do, based on what I have gotten in terms of signs and symptoms. My little student driven brain was, where can I categorize her low back and hip pain?Dysfunction, Derangement, etc. This was my first mistake. I completely lost my ability to focus on the more interpersonal and communication skills needed with this patient. I was not able to step away from my own selfish desire to make sure I could get a PT diagnosis and have something to write in my objective evaluation form then using this time with a patient who was obviously struggling and who has had many medical professionals write her off as another chronic pain, depressed, and hypersensitive patient. I was missing the fact she was telling me what she struggles with, the daily difficulties she has and her obvious demeanor of complete frustration and hopelessness. With the direction of Eric, I started to understand that my drive to get objective data out of this patient was not where my attention and energy should have been directed towards. This patient needed education, personalized care, time to have her view point heard, and needed a health care provider confident that we were going to be able to help her towards patient specific realistic goals. I learned quickly how the communication skills, being able to clearly explain her impairments, and giving her nuggets of information to hold onto throughout the session to boost patient compliance and buy-in. It was a mentally draining experience but I am confident we reached her in a way many other health care providers hadn’t. The verdict of her return is still TBD but I am hopeful!
I found it interesting in this article that it talks about how “the phases of the course of the musculoskeletal disorder can influence the outcomes of care” in terms of patient satisfaction. The article points out that acute patients look for expertise, reputation, level of training and professional behavior compared to chronic patients whom organization of care is the most important. I don’t think until recently I have taken this into account as much as maybe I should. This article does not expand much on this, which is a bummer but, I wonder why that is?
Is it because those who have chronic pain have been bounced around between so many providers they are confused and exhausted of not truly understanding their musculoskeletal disorder? Is it because they have been given a laundry list of medical diagnosis, threatening terms like “bone on bone”, and had every imaging and test done under the sun with little explanation of the results?
I have noticed that most chronic patients are extremely good at laying out their extensive medical history of what this doctor said, the exact date of this imaging/test, the x-rays showed this, etc. But do they even understand what all of that means? These patients have sought so many people for help however they still have NO IDEA what is going on with them in a way they can comprehend or contextually understand. I think this is where we as one of the many health care providers these patients are seeking can be more mindful. Although they may know what their test results are and what the doctor said but do they truly understand what that means for them in a context that is meaningful. That being said, I want to start asking patients “what do you think is going on?” and “What does that mean to you?”. Because what I’ve seen is that you can learn a lot about what this persons expectations, their current prognostic outlook and preferences are by asking this question. Which in this article, clearly shows can make a difference in the therapeutic outcome.
Maybe these patients need more education on what they’ve been told or the lack of what has been said. Maybe using verbal communication that is less medically driven but functionally meaningful to reach their patient specific goals and or address their unique participation restrictions so they can gain some sense of control is where I can improve with my chronic patients. I’d like to get better at taking these black and white diagnosis and impairments that have been assigned to them by their doctors and personalize it to them. Their “bone on bone” doesn’t mean we can’t make progress, get pain relief, or get you back to doing X,Y,and Z. Showing empathy, giving encouragement and recognizing patients opinions is huge.
I can relate to Cameron, in regards of struggling with clear prognosis, I often dread that question of when do you think I will get back to ________, or those patients requesting a timeline. I have been using the phrase “Rome wasn’t built in a day” phrase a lot, whether that is effective or not is still up for debate but it seems to be working for me. I try and use my active listening skills here and say something like “So you said this has been going on for ______ weeks/months/years, so its not going to be an overnight transformation,” then give them functional skills of what needs to happen first before whatever it is they are trying to get back to. I tend to put my foot in my mouth a lot so I try and switch this conversation of the progression I like to see to return to running, throwing, etc. I would love for more tips on how to approach prognostic questions as well!
Last week, I had an initial evaluation with a patient referred for low back pain with sciatica. This man had a history of LBP but currently was experiencing new and more severe symptoms unlike his previous episodes. During the subjective interview, the man was expressing his own theories and worries of what was going on. He was throwing out terms like bulging disc and stenosis. This man was obviously distraught and worried he had really done a number on his back and wasn’t going to be able to go on vacation, cook (his hobby), etc.
After completing my objective evaluation and testing, the first thing I said to him was something along the lines of “Based on my evaluation, you should feel confident that you do not have a bulging disc and there are no abnormal neurological findings.” And if I remember correctly, I hadn’t even gotten to my PT diagnosis before he let out the biggest sigh of relief. I then went on to explain my PT diagnosis using words that were very non-threatening with little medical weight behind them, things like: “your hips are a little stiff”, “your tissues are a little irritated”, etc. It was a profound moment for me to see how delivering my diagnosis and my patient education could give such visible peace of mind…. and hopefully in the long run better patient outcomes (fingers crossed!)
And as much as I would like to take full credit for this myself, I can not. Luckily, this was during mentoring time and with some guidance the importance of prioritizing the relief of this patients fear was definitely eye-opening for me. Self-reflecting on this afterwards, I don’t think I would have weighed as heavily on the way I explained my findings to this man. I probably would have used more medical terminology, assured this patient through more complex explanations, and may have “eaten my own words” for lack of a better phrase.
Since, I’m making a conscious effort to talk to patients knowing that we have both the capability of inflicting fear with too much terminology but also the ability to relieve patient’s anxiety. So when I get those questions like “What do you think is wrong with me/it(insert any descriptive here)?” “Why do I have increased pain when I do X,Y,and Z?” I mean these are the questions we get every day. I try to respond in a way that doesn’t impart fear but peace of mind, or at the least spin the the impairments that are less medical like “the tissues are just irritated, your knee can’t tolerate the load you are putting on them when you work 8 hours a day quite yet” instead of saying “you probably have some degenerative changes under your knee cap and your quadriceps are still really weak and when you are going down stairs….. blah blah blah” I respond in way that doesn’t invoke more worry or anxiety.
And I think Cameron brings up a good point. Does it really matter how well we can explain to them in physical therapy terms and jargon whats wrong with them if all they care about is if we can help them? And I would argue it probably does not. However for me the difficulty lies on being tactful when explaining dysfunction and impairments, because its definitely easier said then done! However, I think this article and these discussions highlight that working with patients requires good verbal communication and the awareness of its impact. I see it as another “tool” or “art” form we have at our disposal to improve our clinical skills and improve patient outcomes.