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I would start by asking questions to determine irritability of her neck pain, and further questioning to rule out red flags and would perform objective tests to rule them out. Then i would want to examine her cervical and thoracic spine for potential musculoskeletal involvement. If patient had high irritability of neck pain then I would want to focus on finding impairments to work on to decrease symptoms. If irritability was low, then I would move straight into tests to examine vestibular/oculomotor function. I would also assess for orthostatic hypotension and autonomic dysfunction based on the CPGs.
Red flags that I would want to rule out are craniovertebral ligament dysfunction and CAD due to the trauma from the fall and symptoms reported. She already had imaging to rule out potential fracture which would have been on my radar due to her MOI.
If the patient denies diplopia, dysphagia, dysarthria, drop attacks, numbness and has negative sharp-purser and alar ligament stress tests then I do not think she needs to be referred out to the ER or back to her PCP. Since I am not confident with concussions, I would refer her to a PT who specializes or has more training to treat patients with concussions. The patient may also benefit from additional mental health services if that was a factor as well.
I would also ask further questions about her symptoms-if they have been worsening, is the pain spreading and referring further down the leg now? does she have any UE symptoms? are the symptoms bilateral? Has she noticed loss in strength or difficulty walking? Or are the symptoms mostly in her SIJ and groin region and is reproduction of symptoms consistent with different movement patterns to determine if it is more mechanical in nature. I would look at UE and LE reflexes as well, including UMN signs (babinski, clonus, hoffman’s). To me this sounds like it could possibly be cauda equina, and if symptoms were not improving and the pt reported that they were worsening I would have her go straight to the ER to be seen. If symptoms were stable and not worsening, then I would have her follow up with her PCP and want her to be seen by a neurologist to get imaging done. I would also reach out to her PCP to update them on her symptoms and talk about POC moving forward.
For cauda equina though, I would expect hyporeflexia and more flaccidity with testing. So if she does have positive UMN signs, then I would be concerned of spinal cord compression further up. I would follow the same plan as stated above based on findings.
Similar to what Clare said, with relation to where her symptoms are, I would be concerned for possible kidney involvement and would examine tenderness at her costovertebral angle on both sides, and ask about N/V or fever for potential kidney infection and refer her back to her PCP if she has positive findings for this.
I apologize for the delayed response. Going off of what Ian and Kyle said, I would want to schedule time and sit down with just the athlete to talk to them about their change in participation. I think it is good to talk with the parents as well, but also have that time with just the athlete since sometimes they may not want to disclose things in front of their parents. I’ve seen it with some parents in clinic who are eager to get their kids back to playing and have high expectations of them which may cause them to close up if they are present during the discussion as Kyle mentioned.
As Ian mentioned and the articles discussed this as well, establishing rapport with patient from the start will hopefully allow them to open up. I would definitely start with an open ended question with the patient asking them what’s going on since their are so many factors that could be involved with this.
Similar to what Ian said, I know there are a lot of pressures and mental challenges that come with playing sports. Coming back from an injury is hard, especially if you feel like you are not where you’re supposed to be prior to playing. I think it’s important to be able to have these conversations with whoever the patient is working with, whether that’s their PT or AT. Also being clear and communicating with the patient about their progress. Maybe the patient did not know how well she has progressed and where her strength was. I know after injuries it’s a mental game and you’re always second guessing.
Based on the information I would perform a 6 minute walk test on the treadmill to help differentiate what is driving his symptoms. If the cramping is coming from stenosis, then I would expect it to be relieved with walking on an incline with more lumbar flexion. If the leg cramping was from the change in medication, I would expect no change in symptoms at an incline.
The article also talked about assessing muscle strength as a guide, and with statin use it can cause increased symptoms and weakness in muscle groups that are not being worked on from my understanding. Since it would be hard to differentiate with muscle testing in the lower extremities from the stenosis vs the statin, I would also test the upper extremities for any change.
1. Disk displacement with reduction with myogenic component
• Can you recreate your pain with pressing the muscles around the jaw? Or does massaging around the jaw help?
• Pain worse with chewing? Eating harder foods?
• Grind teeth at night? pain worse when stressed?
• Is pain flared up with increased anxiety and depression?2. Disk displacement without reduction
• Joint locking?3. Arthrogenic TMD
• Movement restriction?
• Grinding audible noise?4. Upper cervical referral
• Pain with neck movements? Headache start in the back of the head and radiate to the forehead or behind the eye?5. Visceral referral: heart
• Pain with exertion? SOB? Chest pain?6. CAD
• Dizziness? Double vision? Difficulty speaking or swallowing? Sudden falls or feeling of loss of balance? N/T? nausea? Difficulty walking?Hi Kyle,
I think the PT that she ended up with had her try a brace, but the pressure from the brace aggravated her symptoms so she stopped wearing it. I’m not sure what type of brace she tried wearing though.
Since the patient has not received any treatment yet, based on the history provided, I would start with her first and not refer her out to an orthopedic right away. Both of the articles attached, along with the article Ian shared support a multimodal conservative approach for the treatment of 1st CMC OA. The interventions included manual, self massage, dynamic stability exercises, and taping which I would incorporate as part of the treatment. If she does not have any significant improvement in pain or function within 6-8 weeks, then I would refer her out to an orthopedic.
Coincidentally, I had an eval about a month ago for a patient in clinic with similar location of pain, except hers is not presenting like true first CMC OA. Unfortunately, she ended up on another therapists schedule for follow-ups due to scheduling, but recently she had a progress note and was not progressing so the therapist asked me if I would recommend an orthopedic referral. To be honest at the time, I was unsure (also not knowing what they have done the past few weeks made it hard to make a recommendation). I’ll have to share the articles with the therapist for additional interventions to try with the patient. I’m interested to know what the orthopedic doctor will recommend.
Key examination tests for each differential
TFCC: (+) TFCC grind test for pain and clicking, (+) fovea sign-reproduction of pain with palpation of the fovea
Extensor carpi ulnaris subluxation or tendinopathy: (+) MMT-pain with resisted extension and ulnar deviation, snapping sensation heard or felt with movement if subluxed, TTP of the tendon
Chronic distal radioulnar joint instability: increased laxity or mobility noted with distal radioulnar shift test in comparison to the unaffected sign, and possible pain with testing
Ulnar styloid or distal ulnar fracture: notable swelling and bruising over area of pain along with global loss of ROM in the wrist, possible deformity noted with observation depending on the extent of the fracture
Lunotriquetral pathology: (+) ballottement test-increased laxity and pain compared to the unaffected signIf the patient was presenting with positive signs of fracture as listed above then I would refer them to an orthopedic doctor. Also, if he presents with positive signs of lunotriquetral pathology and symptoms were worsening then I would also want to refer him out to help rule out potential necrosis. Overall, for the other pathologies, I would treat conservatively first and if he was not improving with conservative treatment for 6-8 weeks then I would refer him out.
Another great discussion topic. Essays loading…
All of the articles had similar emerging themes that I relate to when looking back on my patient experiences in the residency and with clinicals. We were lucky in school to be introduced to the biopsychosocial model and begin to discuss ways of addressing psychological and social factors and put it to practice in class. However, similar to what was mentioned in the articles, I can feel overwhelmed at times and lack confidence when it comes to translating what I have learned into the clinic with patients. I remember after CSM going to the lecture with Adriaan Louw and learning about how to apply the different metaphors with patients based on their pain presentation and in my head at the time it made so much sense, but it’s not that simple. He mentioned in his lecture that you need to assess the patient’s readiness to learn about PNE before being able to address their different factors. I agree and have learned that the hard way in clinic where I tried to have the discussion too soon with the patient and she straight up told me “you must think I’m crazy” and then not too long after that she ended up going back to her doctor and cancelling the rest of her appointments. Being able to assess when to have those discussions with the patient is hard and is something I am improving on in clinic. At my last terminal experience in school, we had the cup analogy poster on the wall, so patients often looked at it when they came in the room and kind of laugh after reading it. They would often make a comment about it which made it easier to go directly into the conversation about psychological and social factors. I have the cup analogy picture on my computer and need to start pulling it up more often and would like to have it up on the walls as well to start to get the patients thinking more about it.
What also stood out to me was lack of confidence when being uncertain about the patient’s diagnosis. This is something I struggle with especially when the patient is looking for an answer and I can’t give it to them. This makes it difficult with the initial evaluation since you’re trying to establish that baseline rapport with your patient and get buy-in. I think this is when communication is huge and making sure you and the patient are coming to an agreement with plan of care and making it goal oriented. Often though with higher complexity patients, the evaluations take longer leaving less time at the end of the visit to have that discussion with the patient. This is something I want to improve on and find ways to incorporate some of the discussion throughout the evaluation and not just leave it for the end. Another point brought up in the articles is the need to see improvements within session. This is something I also struggle with. I have a patient I am working with now who has more of a stenotic presentation along with bilateral hip pain, and previous surgeries for his knee. After working with him during mentoring, instead of taking a test/reassess approach where nothing changes, we have focused more on movement and making his exercises more tailored to his goals. We also talked about expectations with treatment, what his expectations were and what ours were and what I want to know from him with symptom response with the exercises. Not going to lie, initially I was not always looking forward to his visits since I felt like I did not have a clear direction of what I wanted to work on with him, but since I have changed my approach, I have established more rapport with him and look forward to our sessions now.
This is a topic I’m really interested in and looking forward to reading everyone’s responses. Also, really looking forward to the Adriaan Louw presentation coming up.
Initial differential diagnoses
1.TFCC lesion
a.MOI with high impact hitting the ground
b.Pain located at ulnar side of wrist
c.Describes pain as sharp and deep ache after activity
d.Pain with full weight bearing through his R hand, high impact with hitting the ground
e.Subjective questions: clicking or popping present as well?2.Extensor carpi ulnaris subluxation or tendinopathy
a.Pain located at dorsal ulnar side of the wrist
b.Pain with gripping, impact with hitting the ground, unable to lift heavy weights due to pain
c.Subjective questions: pain with extending wrist? Ulnar deviating? Snapping sensation in the wrist? (for subluxation)3.Chronic distal radioulnar joint instability
a.Initial trauma with hitting golf club against the root
b.Pain located at dorsal ulnar side of wrist
c.Pain with loading and distraction at the joint with full weight bearing and heavy lifting
d.Subjective questions: limited forearm rotation? Clicking with forearm rotation?4.Ulnar styloid or distal ulnar fracture
a.Initial sharp pain and effusion noted in ulnar side of wrist after trauma with hitting golf club against the root
b.Recurrent sharp pain and localized effusion to that area
c.Pain with weight bearing, high impact with hitting the ground, and with gripping/lifting heavy objects
d.Subjective questions: initial bruising noted with effusion? Audible noise when golf club hit the ground initially?5.Lunotriquetral pathology
a.Initial trauma with hitting golf club against the root
b.Pain in dorsal side of the wrist
c.Pain with full weight bearing and with heavy lifting/gripping
d.Pain that has continued since initial onset, with increased sharp pain with aggs and lingering deep ache
e.Subjective questions: weakness with grip strength? Clicking noise with movement?1) This past weekend course was a little eye opening for me with the introduction of heavy slow resistance training vs eccentric training for tendinopathies. I always thought to use eccentric training within the more chronic stage where a patient is coming in with a subjective report of 3+ months of pain. I don’t want to introduce loading too early within reactive or early dysrepair phase to allow adequate time for the tendon to heal. I had a patient come in with achilles tendinopathy who was a runner and was training for a half marathon in September when her pain started. She stopped running and was afraid to keep doing it due to her pain. She had mid-portion achilles pain and had signs of tendon thickening compared to her unaffected side. She also reported increased pain at the end of the day and swelling after being on her feet and walking. She told me she was doing a lot of stretching which was not helping. She came to me about 3 months from when her pain first began and wanted to get back to running, so I started her with eccentric training going off the Alfredson protocol. To me she had been taking it easy, and modifying her activity for 3 months now and needed guidance to start loading her tendon again to get back to running. I think for her since she is a runner, she needs to be able to tolerate repetitive loading to her tendons so the protocol may be more appropriate. However, for a patient coming in with achilles tendinopathy who has a more sedentary lifestyle, or does not need to get back to a sport, eccentric training with Alfredson protocol is excessive and I can see the benefit of using the heavy slow resistance training protocol. I can also see patients having more compliance with that protocol as well from not having to do as much during the week since keeping up with a HEP seems almost impossible at times. Again, I think with most treatments, it should be patient specific and based on their goals and what they need to get back to doing.
2) I haven’t worked with a lot of people in clinic with insertional achilles tendinopathy and the one patient that I have, had psoriatic arthritis which made it tricky with exercise prescription and knowing when to progress/regress exercises. Other than avoiding end range dorsiflexion, for her I modified the load with doing calf raises on the leg press, still working with both knees straight and knees bent and gradually building up her loading tolerance on there. Then I added in body weight DL calf raises in standing working on both concentrics and eccentrics. When I was trying to look up research articles for guidance with treatments and loading for insertional tendinopathy, most of the articles were focused on mid-portion tendinopathies. I think the heavy slow resistance protocol is a good guideline to use with modifying position, but allows the pt to work in both unloaded and loaded positions.
3) I get asked this question often in general when I do eccentric training with patients and find myself struggling with providing a good explanation. I often explain the difference in concentric vs eccentric if they are not familiar with the differences and how with concentric the muscle is shortening and eccentric the muscle is lengthening. With eccentric loading they are able to work higher loads compared to concentrics to help improve muscle strength and loading tolerance. I try not to go into the specifics since that’s when I start to muddy the waters. I would be interested to hear other go-to explanations and what you say when people start to ask for the more specifics. This is definitely something I need to brush up on.
References
1.Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. 2009;43(6):409-416. doi:10.1136/bjsm.2008.051193
2.Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. 2015;43(7):1704-1711. doi:10.1177/0363546515584760Great questions Ian. To be honest I have not had any patients so far that are post-op shoulder so I can’t provide any recommendations based on my experience. I think you bring up a great point that is different between protocols for post-op patients. In the article attached it brought up that patients with the subscap repair who were held off from physical therapy treatment initially did better versus others who started physical therapy earlier on. I think this comes down to confidence with knowing tissue healing time frames, considering the patients PMH and PLOF, and assessing symptoms and response to treatments to know how to progress/regress treatment as appropriate.
Going off of Ian’s response, the article even pointed out that most of the rehab protocols are clinical commentaries that lack high quality evidence and consensus between them. I don’t have as much experience working with post-op patients, but whenever I look up a protocol to use I often find this myself and how some of the protocols contradict one another which makes it confusing as a new grad. Especially when the timelines and precautions listed don’t match up with each other which the article mentioned for both the TSA and RTSA protocols. I agree the article points out the importance of using evidence based practice when it comes to using the protocols. Another PT at my clinic also mentioned he just uses them mostly as a guideline as well and adjusts it as needed.
Awesome post Ian, I really enjoyed reading your response. The first part of your post reminded me of when I was at the military clinic, for some reason radiofrequency ablations were very common for people with low back pain which would maybe help for the first 6 months and then their pain would come back. One of the guys I saw with my CI was dealing with PTSD and was struggling to find a psychologist that he trusted to talk to about what he’s been through. He had persistent low back pain and had already gone through an RFA which surprisingly did not help the pain long-term. It was really difficult to hear what he is dealing with and what he has gone through. I can’t help but think if his providers initially took a more biopsychosocial approach, his symptoms would have been different.
It was also very common during that clinical that the providers didn’t talk to their patients about their imaging results so they would ask me to explain it to them. At the time reading the results, there were things I didn’t fully understand and would have to look up. It was difficult having to explain the results to the patients and I could definitely tell at times I used words that I should not have that the patients held on to. I also really like that phrase from the O’Keefe et al. article and will use a version of that when I’m talking to patients in clinic.
Managing patients with NSLBP or persistant pain conditions is a hard skill and I’m excited to take the course with Adriaan Louw to learn more about PNE and applying it during treatments with patients.