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I would start this evaluation by determining if the patient is appropriate for PT treatment, while keeping in mind irritability levels due to the acuity of symptoms. I would want to rule out a more serious brain injury, cervical spine injury other than fracture including any ligamentous injury, and cardiac/arterial involvement.
Determining irritability would first involve questioning regarding exacerbation of symptoms with neck movement, then HA and dizziness severity as high irritability of symptoms would limit the tests/measures performed at initial evaluation. I would then clear any ligamentous insufficiency by performing the transverse and alar ligament tests as well as sharp purser.
After determining that the patient’s symptoms are highly irritable and that the ligamentous tests are clear, I would then assess cervical and thoracic regions for any MSK impairments that would require low level exercise/movement to begin treatment. Due to the patient’s HA and dizziness I would perform some oculomotor and vestibular tests (visual tracking – smooth pursuits, saccades, convergence to start); however limit this due to her irritability level.
I would have the pt follow up with her PCP if they were not already involved with her care and refer to a neurologist if a more serious brain injury was suspected.
For this visit, I would inquire further about these new onset of symptoms – when they started, if they remain; has the pt been able to urinate without pain and without lingering feelings of fullness? Has she had any instances of incontinence? I would also inquire about strength, dropping of items and walking ability/balance. For objective testing, I would do a neuro screen including: UE/LE reflexes, UE/LE myotomes, LE dermatome testing (UE if indicated from questions). I would also check UMN signs including inverted supinator, babinski, clonus and ataxia. I would be concerned about possible cauda equina syndrome with this pt or possible issues related to the kidneys(although this would not explain the groin numbness). I would refer this pt to neuro for MRI imaging of the low back to be performed in order to rule out compression of the spinal cord.
In response to Kyle’s post. I would approach this differently for a 24 year-old. I think that potential stressors and effects of mental health are a lot different at this age; likely including work/school, finances, relationships – all of which could be impacting the pt’s performance. That being said, this may not be something the pt wants to discuss with their PT and I could offer counseling services or other specialists if it seemed appropriate.
I would also most likely only talk to the 24 year old themself and try to understand what they are going through rather than speak to a family member or coach; unless the behavior seemed severe or destructive.
In regard to the initial question and like Ian and Emily said, I would try talking to this pt one and one first. Hopefully with enough rapport established and with some open-ended/non-confrontational questioning the pt would open up to me. I think that if I had a successful conversation with the pt herself and depending on the parents amount of involvement, I may keep the conversation between myself and the pt for a session of 2 to determine any change in behavior and then involve the parents if the behavior continued or seemed to become destructive.
Growing up, sports were very competitive for me and I was in PT for injuries as early as 10 years old. Thinking back to my experiences in PT, especially with my ACL recovery at 15 years old, I did not have a very substantial relationship with any of my PTs. I think in practice now, I try my best to build rapport with pt’s because of these experiences.
Even though sports were competative for me back then, the intensity of kids sports has only increased. This pt may be experiences external pressures or possibly not feel like she is back to where she should be with her progress even if she tests strongly. This was one situation I experienced in which my PT and coaches allowed me to return to sport; however it took much longer actually playing the sport to feel 100% again and this took a heavy mental toll of not feeling good enough/being pressured by coaches to improve faster. If this situation was occurring – it may make more sense to get the coaches/parents involved to explain progressions/return to sport strategies.
After reading this article, I would administer the 6MWT or another functional test like the 5xSTS or 30second STS especially if one of these was a measure that I had taken during the initial evaluation. Having a baseline measurement at initial evaluation would be ideal to determine if the pt was improving or not at this visit. If these tests showed unexpected declines in function or large differences compared to age match norms I would be more concerned of statin-related myopathy. I would expect the pt to be showing some improvement by the 6th visit, so if this was not the case, I may be more suspicious of medication related changes.
It may also be helpful to take MMT measures and compare these to baseline. If there was no improvement of decrease in strength from initial evaluation this would make me more concerned about the change in medication and possible myopathy. I would also take note of if the patient was complaining of wide spread fatigue/weakness and do MMT for additional areas like scapular or shoulder musculature. I would not expect the patient to be fatigued in these regions if we were focusing on the LEs so this may be another indication of statin-related myopathy.
Ant disc displacement with reduction; joint clicking,
Q: Are you able to fully open and close your mouth? Do you clench or grind your teeth? Have you ever worn a night guard or retainer?
If ROM restricted, would consider anterior disc displacement without reduction; but this is less likely due to the constant clicking.Capsulitis; stress, duration of symptoms
Do you have pain at rest? Are you able to fully open and close your mouth? Is the TMJ painful to touch?OA of TMJ; four year duration, would expect more grinding than clicking
Q: Are you able to fully open and close your mouth? Do you notice any grinding at the TMJ?Rheumatoid Arthritis; age, female,
Do you have additional B joint pain? History of RA in family? (+) rheum factor?All of the above may have myogenic contribution due HA in head/jaw and stress, anxiety and depression component.
All above likely have cervical component due to HAs into head and jaw pain.Case 1:
TFCC tear d/t subjective relevant info: ulnar sided symptoms, local effusion, 4 month hx, traumatic impact/injury to wrist, quality of symptoms – sharp with movement and lingering ache, WB sensitive.
Q’s Does the pt have any clicking or snapping at the wrist?
Objective: (+) pain with forearm pronation supination, (+)TFCC compression test, (+) pain with palpation, (+) ulnar fovea sign,
DRUJ instability d/t subjective relevant info: ulnar sided symptoms, 4 month history, WB sensitive, weight lifting agg.
Q’s: Does the pt have loss of ROM of wrist? Are symptoms elicited with forearm pron/supination?
Objective: ROM limitations into pron/sup, (+)DRUJ ballotment test,(+) dorsal RU shift test
ECU sublux/instab d/t subjective relevant info: ulnar sided symptoms, MOI involving traumatic impact to wrist in extension, intermittent effusion, pain with golf swing – extension of wrist.
Q’s: Is there pain with extending or ulnar deviating the wrist? Has the pt noticed a snapping sensation at the wrist?
Objective: (+) pain/possible sublux with ext/UD MMT, (+) palpation of tendon for pain
Distal ulnar fracture d/t subjective relevant info: 4 mo hx without relief of symptoms, traumatic impact to wrist, WB sensitive.
Q’s: Was there a “pop” felt/heard with initial injury?
Objective: (+) pain with palpation of distal ulna, ROM loss/pain in all directions, – Pt would be referred out if presentation for this was (+).Case 2:
Barring any clear indications/red flag findings that a pt is not fit for PT treatment, I always feel that trying conservative management before referral is best. I realize this is bias and upon reading these articles, there is actual evidence that would support this decision. This clinical decision making is based on the provided evidence in these articles that symptoms of CMC OA respond positively, in terms of pain levels and function, to conservative management using the dynamic stabilization approach. Due to the pts recent increase in symptoms over the last 3 months from increased activity level involving more lifting and holding she would likely benefit from not only intervention aimed at the CMC but general strengthening for the wrist and forearm as well to support her new lifestyle. With this patient becoming the primary daycare provider for her granddaughter it may also be more difficult for her to pursue the surgical/orthopedic approach and be unable to care for her granddaughter during that time. Looking at this case from a holistic approach there are multiple reasons that considering PT treatment first would be in the patient’s best interest.
Side bar: Sincere apologies for the VERY late response to these posts. I read through all the responses and it was insightful and a great reminder of how little I understand wrist/hand pathologies. I certainly need to brush up on these subjects and this discussion post has been helpful in initiating that.
1. I think that the decision for incorporating eccentrics in the management of tendinopathy is multifaceted. Often I think of using eccentrics when the pt can tolerate that increased amount of load with low irritability. If the pt can stop the eccentric exercise and feel “no worse” I usually think it is appropriate to carry on. This may be the patient that falls into the tendon dysrepair/degenerative tendinopathy vs the reactive tendinopathy. Objectively, I think of this as the pt with full PF/DF strength, possible painful muscle contraction into PF/DF.. This pt may have reduced DF ROM and pain with palpation of the tendon. This pt may engage in some sort of functional repetitive task that is part of their daily/almost daily life. They may have history of achilles pain on/off for years as well as fluctuating pain levels when performing tasks; there may be a “sweet spot” of time when they don’t have pain, but likely start and end the activity with it.
2. Some other modifications might include not stretching or mobilizing in a full DF position as well as avoiding high loads or high impact exercises until tolerated with minimal to no pain in order to not increase strain/compression of the tendon. If eccentrics don’t work I’d likely continue treating the impairments through stretching, mobilization, and strengthening concentrically/isometrically as well. When researching treatment for insertional achilles tendinopathy, I had difficulty finding substantial evidence for exercises other than eccentrics and most articles refer to ESWT as the next line of treatment. The first article in my reference list discusses the compressive forces on the achilles tendon at its insertion during DF as recorded with ultrasound which supports the idea of reducing exercises into increased DF ROM for pts with insertional achilles tendinopathy.
3) When explaining the mechanism of eccentrics to patients, I think that I try to explain concentrics first as I feel that more people recognize this type of strengthening. Then I say that eccentrics is “just a different way of working the muscle – it has to exert control and work harder through the entire ROM or full lengthened position of the muscle. I go on to explain that this is why “I want you to do this exercise slow and controlled.” I tend to pair my education with examples so I might show them what it looks like when their calf musculature is shortened vs lengthened and how eccentrics work from there by demonstrating myself. In terms of why eccentrics work, I think I just tend to say “well, research shows that….” and then ramble on from there and I don’t think I’ve had any patients looking for a specific reason for “why” yet. I should probably change my approach to this and try to offer a better explanation. From the research I’ve done thus far, it looks like there are various reasons that we think eccentrics are helpful from structural tendon adaptation to changing tendinous stiffness to neuromuscular output changes and more research is needed to determine the most likely reason for the benefit.1. Chimenti, R. L., Flemister, A. S., Ketz, J., Bucklin, M., Buckley, M. R., & Richards, M. S. (2016). Ultrasound strain mapping of Achilles tendon compressive strain patterns during dorsiflexion. Journal of biomechanics, 49(1), 39–44. https://doi.org/10.1016/j.jbiomech.2015.11.008
2. O’Neill S, Watson PJ, Barry S. WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY? Int J Sports Phys Ther. 2015 Aug;10(4):552-62. PMID: 26347394; PMCID: PMC4527202.
3. Dilger, C. P., & Chimenti, R. L. (2019). Nonsurgical Treatment Options for Insertional Achilles Tendinopathy. Foot and ankle clinics, 24(3), 505–513. https://doi-org.ezp.slu.edu/10.1016/j.fcl.2019.04.004
“Maybe they’ve had a lot of manual
therapy but they have not had my manual
therapy.”This quote from the Slade (2011) article made me laugh and I’ve most definitely never thought that when treating patients. I was honestly surprised by the articles I chose to read. The PT’s that were interviewed came off as lacking empathy and being quite pessimistic. Some of the responses seemed very judgmental especially in stigmatizing patient’s with chronic low back pain. Some of the quotes in these articles states that these patients are selfish, only think about themselves or are simply attention seeking. So maybe this is the type of attitude you develop as a seasoned PT and have seen large amounts of this type of patient?
In my short few months as a licensed PT, I don’t think I’ve ever thought of patients in this way – especially patients with chronic pain. I always try to empathize with them and realize that their pain experience is real no matter how outrageous or exaggerated it may seem. I figure that most of these patients have been let down by the healthcare system, are frustrated and typically very unclear about what is going on with their symptoms.
In regard to parts of the articles that did resonate with me, I think that I do find it difficult to give patients a specific diagnosis when there is no clear pattern. Like the Slade article mentioned I tend to move more toward explaining impairments and addressing the patient’s questions that way. I wonder if these is enough for some of my patients and typically ask “Does that make sense?” to try and gauge their understanding. Unlike some of the clinicians quoted in the article, I typically do not give into the imaging and use that as buy-in for the pt.
I think that I was provided decent education regarding addressing psychological and social factors. Part of the difficulty for me is figuring out timing and when is best to bridge that gap with the patient. I do my best to simply listen if the situation does not resonate with me and agree with them or validate their feelings. I think I struggle sometimes with giving people concrete ideas/strategies to address their social or pyschological factors but in those instances sometimes even just listening to their concerns seems to be enough. I think a lot of times we become sounding boards for our patients and in my mind that is therapeutic and an important part of care. I try not to skip over or ignore patient’s comments that include social or pyschological factors because it does relate to our care. We are a niche of the healthcare world that gets increased time with patients and I think that lends to creating good relationships with our patients and supporting them in any way we can – whether physically, emotionally or mentally. Of course there is a limit to this and at some point there are issues that are out of our scope of practice, but I think it’s a mistake to say that we don’t have any role in address social/pyschological factors.
Articles reviewed:
Slade, S. C., Molloy, E., & Keating, J. L. (2012). The dilemma of diagnostic uncertainty when treating people with chronic low back pain: A qualitative study. Clinical Rehabilitation, 26(6), 558–569. https://doi.org/10.1177/0269215511420179Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: A systematic review. Journal of Physiotherapy, 61(2), 68–76. https://doi.org/10.1016/j.jphys.2015.02.016
1. I think that the decision for incorporating eccentrics in the management of tendinopathy is multifaceted. Often I think of using eccentrics when the pt can tolerate that increased amount of load with low irritability. If the pt can stop the eccentric exercise and feel “no worse” I usually think it is appropriate to carry on. This may be the patient that falls into the tendon dysrepair/degenerative tendinopathy vs the reactive tendinopathy. Objectively, I think of this as the pt with full PF/DF strength, possible painful muscle contraction into PF/DF.. This pt may have reduced DF ROM and pain with palpation of the tendon. This pt may engage in some sort of functional repetitive task that is part of their daily/almost daily life. They may have history of achilles pain on/off for years as well as fluctuating pain levels when performing tasks; there may be a “sweet spot” of time when they don’t have pain, but likely start and end the activity with it.
2. Some other modifications might include not stretching or mobilizing in a full DF position as well as avoiding high loads or high impact exercises until tolerated with minimal to no pain in order to not increase strain/compression of the tendon. If eccentrics don’t work I’d likely continue treating the impairments through stretching, mobilization, and strengthening concentrically/isometrically as well. When researching treatment for insertional achilles tendinopathy, I had difficulty finding substantial evidence for exercises other than eccentrics and most articles refer to ESWT as the next line of treatment. The first article in my reference list discusses the compressive forces on the achilles tendon at its insertion during DF as recorded with ultrasound which supports the idea of reducing exercises into increased DF ROM for pts with insertional achilles tendinopathy.
3) When explaining the mechanism of eccentrics to patients, I think that I try to explain concentrics first as I feel that more people recognize this type of strengthening. Then I say that eccentrics is “just a different way of working the muscle – it has to exert control and work harder through the entire ROM or full lengthened position of the muscle. I go on to explain that this is why “I want you to do this exercise slow and controlled.” I tend to pair my education with examples so I might show them what it looks like when their calf musculature is shortened vs lengthened and how eccentrics work from there by demonstrating myself. In terms of why eccentrics work, I think I just tend to say “well, research shows that….” and then ramble on from there and I don’t think I’ve had any patients looking for a specific reason for “why” yet. I should probably change my approach to this and try to offer a better explanation. From the research I’ve done thus far, it looks like there are various reasons that we think eccentrics are helpful from structural tendon adaptation to changing tendinous stiffness to neuromuscular output changes and more research is needed to determine the most likely reason for the benefit.
1. Chimenti, R. L., Flemister, A. S., Ketz, J., Bucklin, M., Buckley, M. R., & Richards, M. S. (2016). Ultrasound strain mapping of Achilles tendon compressive strain patterns during dorsiflexion. Journal of biomechanics, 49(1), 39–44. https://doi.org/10.1016/j.jbiomech.2015.11.0082. O’Neill S, Watson PJ, Barry S. WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY? Int J Sports Phys Ther. 2015 Aug;10(4):552-62. PMID: 26347394; PMCID: PMC4527202.
3. Dilger, C. P., & Chimenti, R. L. (2019). Nonsurgical Treatment Options for Insertional Achilles Tendinopathy. Foot and ankle clinics, 24(3), 505–513. https://doi-org.ezp.slu.edu/10.1016/j.fcl.2019.04.004
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Hi everyone, sorry I’m jumping into this discussion a little late! I happen to keep getting post-op shoulder EVALs actually. In regard to your most recent question Ian, activation of the RTC muscles too early and too much is something that I am typically worried about. I’ve gotten conflicting information not only from protocols, but other clinicians in clinic. I know that some wait 6 weeks at times to begin submax isometrics if the pt is over 65 and therefore they progress a lot slower than the pt’s I’m seeing who are younger. I think Emily’s point of being confident with tissue healing time frames, PMH and PLOF is the way to go. I’ve been basing my progressions off of this and the pt’s own response to active motion – typically waiting until between 6-8 weeks to really start more active motion/strengthening with any resistance based on the patients progress thus far.
I found this week’s discussion topic to be very relevant to recent patient encounters – even those not related to LBP. When reading the topic, I could immediately think of multiple patients that I have struggled to explain their pain in a specific manner. I do find that I try to be more vague when explaining my hypotheses to pts. I think that I do this because in my perspective, I would rather the patient have a non-specific answer than believe that they have a “disease” or “condition” that they need to have imaged or go through extensive surgery to fix. I can tell that most patients are not satisfied with my explanations and I often have to reiterate myself over several visits due to the patient’s repetitive questions regarding an explanation for their symptoms. In order to remedy this situation, I think that I could learn a lot from approaching conversations like Peter O’Sullivan exemplifies in the videos. He is able to keep the explanations simple yet informative and evidence based. Clearly, much of our treatment with LBP is breaking stigmas and I couldn’t help but laugh at some of the video examples as I noted that I have definitely given some unhelpful advice to patients without realizing it.
Watching the videos, it seemed so blatantly clear what was helpful and unhelpful so it surprised me to think that I have used the unhelpful language with my patients. As a new clinician, I think that sometimes I am trying to come across as knowledgable and confident and this can lead me to be unaware of how I am phrasing things that may give patients the wrong idea about their symptoms. For example, I think that I tell patients to “let pain be their guide” in a different manner, but while I try to emphasize that just because something is painful, doesn’t mean that they can’t do it, I wonder if my explanation truly comes across that way. While watching the clips, I also noted that sometimes I brush aside unhelpful or untrue comments that the patient brings up themselves. For example, I often have patient’s bring up that the exercises are helping their “posture” or that they “need better posture”. Occasionally I will dive deeper into this and explain to patients that there is not truly one great posture, but other times I just nod and move on. After watching these videos and reading the articles – I wonder if this is a small aspect that I could better address with patients to help break the back pain stigma.
Furthermore, when reading the O’Keefe article, I found the outcomes related to the labeling of the patients symptoms to be fascinating. Recently we have been told not to use the ICD-10 code “low back pain” and instead use extremely similar codes that are “low back pain, unspecified” or “vertebrogenic low back pain”. All of the codes seem exceedingly generic, which as the Lim article explained is a clear mismatch between what patient’s want and what health providers believe is most helpful. With that being said, I think it’s interesting that the O’Keefe study showed that people who were given these generic labels perceived less need for imaging, better prognosis, less need for second opinion, etc than those who received more specific diagnoses. Knowing the results of this study, I think it shows that we should try and find a “happy medium” where we can successfully give patients more generic explanations for their symptoms and load them with evidence/knowledge surrounding LBP, posture, lifting mechanics etc in order to decrease the stigma with low back pain as well as reduce the unnecessary rabbit hole of healthcare appointments/intervention that so many of our patients fall down.
I enjoyed reading this article as I think it has been quite relevant to many of the patients I have recently treated. In a recent reflection post, I wrote about a patient who became frustrated with the care I was giving and even stated that he was about to walk out of the appointment. I certainly think that he would believe this appointment started as a non-encounter. There was clearly a mismatch between his expectations and my proposed treatment. While reading this article, it was interesting to me that a few of the positive features of patient encounters were actually points of contention for this patient. During our time together, I tried to give him autonomy and the space to talk about his experiences. I tried to take more of a “coach” position and guide him with treatment. This approach backfired as it seemed that the patient felt that I did not have a clear treatment plan. In the future, I think that I need to read the patient better, obtain clear expectations and set the stage early regarding my method of “working together” with the patient so that I do not come across as unconfident or unknowing of where to take the treatment.
On the other hand, I have been working with a patient with chronic (at least 20 years) of mid thoracic pain and felt that I have moved the pt toward autonomy. This has been a gradual process, but I think that it has been achieved through listening to the patient, gently getting more information about her prior treatment experiences and acknowledging her fears. We have been moving slowly in terms of exercise progression and I emphasized early on that I do not want to flare-up her pain and put her out for multiple days. This immediately appeared to be a relief to her and she seemed to leave the initial eval with some hope as she verbally expressed. I have also explained that this is a teamwork approach and that we need to find the treatment that works best for her which involves both of our input. In the MacNeela, Doyle, O’Gorman, Ruane, and McGuire study that was cited within the Holopainen study, the idea that active listening and bedside manner having a large impact is discussed. It explains that having a good connection and listening was important even when pain was not resolved. I think that I have seen this during the time with my patient because since she trusts me to a certain extent she is willing to try exercises or methods that she may have initially been unsure of.
With sources
Holopainen, R., Piirainen, A., Heinonen, A., Karppinen, J., & O’Sullivan, P. (2018). From “Non-encounters” to autonomic agency.Conceptions of patients with low back pain about their encounters in the health care system. Musculoskeletal Care, 16(2), 269–277. https://doi.org/10.1002/msc.1230
MacNeela, P., Doyle, C., O’Gorman, D., Ruane, N., & McGuire, B. (2015). Experiences of chronic low back pain: A meta-ethnography of qualitative research. Health Psychology Review, 9(1), 63–82. https://doi-org.ezp.slu.edu/10.1080/17437199.2013.840951Hi Emily,
Thanks for you insightful post! When I read your answer to the first question, I felt like I had the same thoughts. I definitely feel like I have more biases around LE and spine surgeries mostly because I have treated more individuals with impairments in those regions and feel like I know more about those surgeries. Treating the shoulder/understanding implications for surgery/surgical outcomes is definitely one of my knowledge gaps. I think I would approach patient interactions regarding surgery the same way. Plainly stating that they may want to consult with a surgeon due to the lack of progress/other objective data. I think keeping it objective would help in those situations. Depending on my rapport with the patient, I think I would also approach any questions regarding surgery very honestly and cite facts that I do know as well as indicate when I simply do not know or when I do not have a great answer to their concerns.