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Hey Cam –
It’d depend on the patient’s irritability level, but I think a safe bet would be either upper limb tensioners reflecting the positive obj test on the contralateral side or a glider/ slider on the affected side with the hopes of decreasing nerve tension and improving nervous irritability. What do you think?
1.What are your top three diagnoses based on the subjective information? (ranking order)
– c4/5 radiculopathy
– 1st rib dysfunction
– TOS2. Based on the subject info, what would be your top priority objective tests and why?
– TOS testing, first rib spring test, tinel’s, hand dynamometer, Spurling’s, scalene length
– functional observation of assumed desk posture or how she chooses to push an object
– determine catastrophization of her sxs (reports 10/10 pain in the last 24 hours, but sxs are achey and numb?), determine how she views her problem, its origin, what she feels like will improve her problem, and her relationship with pain in the past.3.What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
C4/5 radic:
– R UPA to these segments generating familiar paresthesia
– R rot (closing down) and L SB (tensing nerve) painful –> UT slackening improves this … could also be interpreted as slackening nerve group in the upper quarter
– Left forward quadrant painful (tensing nerve), Right forward quadrant painful (closing down d/t SB and rot)
– + spurlings, ULTT 1
– myotomal weakness to C4/5 related mm groups
– structural observation of TS kyphosis… could also mean lower CS in extra extension closing down?4 What subjective and objective information do you feel is missing and would have been helpful to assess with this patient? (Key information, keeping in mind this is a one hour eval)
– Observed functional testing that may lead to better understanding of how her body is choosing to move
– TOS testing
– hand dynamometer to determine if it’s a purely sensory deficit distally5.What would you test in the next follow-up treatment session?
– 1st rib or TOS
– Scapular performance
– reflexes
– DNF endurance6. What would you have given patient for her initial HEP?
– Explain pain video (she works 60hr weeks and is describing 10/10 NPRS pain.. could need to destress and push education)
– nerve gliders
– Picture of a basic ergonomic set-up to model her work station afterI think that’s a great point, Casey. To be honest, my time in Los Angeles was a great period where I could work on my manual and prescribed exercise skills, but my patient education skills suffered. A strong portion of my daily patient pop was from Mexico, so in addition to a language barrier the patients also had strong reverence for any medical professional and embodied a “whatever you say, doc” attitude minimizing my need to justify my plan. I felt this contrast now working in a suburb of Richmond, and I know I missed the mark with a few patients simply because I didn’t draw the connection between the patients’ impairments, my plan, and their goals and values. I can definitely say this super simple shift in my prioritizing has improved patients’ outlooks on their prognosis, objective outcomes, and their senses of self efficacy.
Wow, I’ve really enjoyed the discussion on the hip articles so far. I agree, it can be easy to beat around the pinata a bit when it comes to critically evaluating a study. Cam, I’m 100% with you that it seems unlikely to say that the participants actually adhered to the HEP as well as they did (85% compliance). It’s even more strange this is considered “excellent” when this is supposed to be the main bulk of their rehabilitation focus (since the participants are cumulatively receiving 6hrs of in-tx care over the course of 3months with hands-on care that gradually tapers away to just 30minute sessions received every 2 weeks).
My biggest takeaway here is the real benefit of the placebo effect. One group was seriously regulated to not even exercise during the 3month period and solely received inactive ultrasound from an experienced clinician and yet both groups showed significant improvements in both pain and function. This makes me revisit my tx frequency and duration expectations and wonder if weighing education higher than manual or perhaps exercise can be more appropriate for some patients.. How would you guys weigh the value of these approaches for this patient pop?
Casey, I raised an eyebrow at that protocol (thinking back to my experience receiving a hernia repair surgery, having a hard time just climbing stairs). Cam, I wonder what’s a smart way to test the ratio? 1RM?
I appreciated how the article suggested we begin the exam with a global attempt to rule OUT involvement from other structures, followed by an attempt to rule IN local involvement that may indicate AP. It’s cool to think about different approaches to an exam, especially when you’re in an area that lacks research for guidance. Further, I appreciated its attempt to simplify a really muddy area, and really it just recommends we stick to our roots. Figure out what it’s not… do your best to find a supporting argument for what it most likely is… then place the patient into treatment “buckets”… pain / ROM / strength and go from there. That’s a really applicable framework that I know I often get lost from when I’m in the moment attempting to find the most important information for this evaluation.
I have 2 big take-aways from the second article. The first being that it’s important to circle back to the anatomy. The GMax and GMed muscles each have varying fiber direction, influencing their action. This means that we can provide a base exercise, such as a lunge, and alter it slightly (maybe with a forward or backward lean) to more specifically engage these portions of the muscle belly. I love this reality for its clinical applicability, as it allows me as a clinician to broaden my perspective for the bank of exercises that are useful. Likewise, specifically engaging a portion of the muscle belly may aide in overall muscle activation, whereas focusing on a single exercise (such as using clamshells at 30deg hip flexion but not also including 60deg hip flexion) may bypass a portion of the target muscle.
My second take-away is how functionally eye opening this article can be. By realizing the broad variety of postures that are proven to engage GMax and GMed, I can more specifically provide graded progression to my patient’s goal task. We may start with sidelying clamshells or supine bridges, progress to quadraped or planks, and end with variable stair climbing (lateral, forward, retro). I think this can also generate better patient buy-in, if they can see the natural progression of exercise from sidelying to actually using a stair (rather than progressing from yellow theraband clamshells to black theraband clamshells).
Love the post, Eric.
I have to agree with you guys. One thing this article (and VOMPTI) has really made a difference in my treatment approach is to bolster my educational component. Eric really laid it out there simply in the last VOMPTI course that as PTs we have 3 tools: manual, exercise, and education. I lacked so badly the educational component, and it’s super obvious now that it’s arguably the most powerful tool in our toolbox. If a patient for instance isn’t aware of simple do’s and don’ts (and WHY to/not to) related to their pathology, such as hip ADD during glute tendinopathy, then they’re more likely to feel helpless or passive in their treatment. Patients desire to understand. They want to feel in control. We can make a difference in their prognosis just by improving their outlook of their case.
Jon, it seems like the painful side sleeping may be mechanically driven with regards to the tendon insertion and/or bursa. With this in mind, it’d make sense to me that a method to soften the pressure on the area would provide most relief. (Though I’d be interested in other folks’ thoughts).
I really appreciated the article’s likening of the gluteal tendinopathy to that of a RTC, and I could see patients appreciating this anatomic parallel to help them better understand what kind of pathology they’re experiencing.
My biggest takeaway is how mechanically driven the pathology is, and with this in mind I feel as though I can be more creative to provide useful tx exercises that most mimic a patient’s environment.
1. What are your top three diagnoses based on the subjective information? (ranking order)
– disc referral
– paraspinal myalgia
– facet arthropathy2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
– Central nerve tension: you’ve cleared isolated cervical flexion as a generator of familiar pain, however cervical flexion as a structural differentiation to + Slump recreates shoulder blade pain; PSLR recreates LBP, and Hip ROM WNL without strong recreation of her pain (I’d be interested in what ROM somewhat recreates this).
– Paraspinal myalgia: She has (B) sxs at the shoulder blades and around L4/5. The narrative of her story fits, as these supporting mm groups may be in a more protective mode d/t 2 accidents relatively close together. This could fit with her aggs and sx quality, as flexion, returning from flexion, and lifting would require these mm groups to kick on/ stretch. It’s also noted that she has inc turgor and apparent tone with tenderness to touch.
– Facet arthropathy: Although both MVAs were at relatively slow speeds, they occurred in cardinal planes requiring facets to flex and sidebend. This pathology fits with the aggs, nature, quality, and location of her sxs. That being said CPA to TS and LS didn’t recreate her sxs.
3. What subjective and objective information do you feel is missing and would have been helpful to assess with this
patient?I’d want to know more about her hip AROM/PROM to differentiate its involvement from LS. I’d want to know more about her scapular stabilizers and PQRS, since she reports that movement is harmful to her. I think a resisted trunk extension test would be a good tool to differentiate a myalgia impairment from a facet or disc impairment.
4. How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this
patient regarding prognosis?I think being in 2 car accidents close together feels like a yellow flag, since she’s probably more frustrated and is likely to feel like she deserves good care. That being said, she was a trooper and simply walked to the ED after the MVA.
She seems really cautious with her movement, so I’d keep it simple and draw a relationship between her current status and her ability to heal appropriately after the first MVA.
5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie
regarding patient education, manual therapy techniques, therapeutic exercises, etc.I’d try to build her sense of self-efficacy quickly by giving her meaningful, functional tasks that she can accomplish pain-free. I’d keep it as active as possible, with concurrent respect to the needs of her pathology and potential pt value of needing to feel cared for. HEP could be movement-based, rather than exercises.
Love it Casey!
Cam
I love how clear this article makes its point, and the graphics can be great tools to visibly support our discussion with a patient who has no background knowledge (and may have a predisposition toward surgery). As a clinician, having knowledge of good studies like these are tools on the table that we can use to help shape a person’s understanding of the proverbial scales when it comes to comparing one option over another; that being said, we have to remember the power of perception.
Not everyone will look at a visual diagram or respond to the recitation of research equally, we have to parallel with the patient for the tool to be effective. A good example is a new patient I had yesterday. He begins the evaluation simply communicating that he’d had poor experience with PT prior, and he’s frankly unsure if we can help him with his diagnosis (s/p axillary lymph node removal resulting in gross paresthesia and local hypersensitivity to his triceps). He’s basically asking for concrete evidence, and Laura and I were able to show him a desensitization protocol and some research demonstrating how we can be effective. For others, this might not mean as much, and it’s our job to recognize that we’re not just a clinician talking to a patient. Every treatment is a human interaction between people, and we can be more effective if we take the time to understand our patients and tease out important viewpoints for their care.
Casey, it might be helpful to just continue having an open but intentional conversation to see his viewpoints. This can be a foothold for more conversation and potentially more effective discussion.
Jeff – Matt – Cam
I agree that this article standalone will appear to take a halfhearted look at the effectiveness of PT in its role in conservative management before surgery; but I think this viewpoint actually adds to the already saturated bank of research supporting PT’s potential superiority.
Existing research, to my knowledge, supports marginal superiority of PT > meniscal repairs in instances without mechanical blocks. With this article, we can make a stronger argument to support the utility of PT before surgery by stating that we’re non-inferior (or comparable, more like). APM surgeries cost around $4 billion, so if PT is comparable then this definitively should be the primary recommendation rather than introducing an expensive trauma (surgery) to the patient.
Cam, your case example is probably one of the most common discussions PTs have with patients who’ve experienced an injury-related event. Ultimately, the medical world is going to need to start using the existing bank of research as real-world guidelines to guide patients into the right doors (PT vs surgery vs specialist). PTs are fighting an uphill battle against cultural norm, so it’s more important than ever for PTs to be fluent in the current literature. I’d take an approach similar to yours, and maybe even go over the article in-person to make my viewpoint less of a “claim.”
Hey Erik, Erik here.
I really agree. When we decide to devote our lives to PT, we’ve chosen the glamorous side of patient care. It’s a hard realization that realistically documentation is equally as important as good patient care to be a good medical provider. That includes documenting relevant conversations with other healthcare practitioners involved in the patient’s care, important patient notes, and decisions for upcoming treatments. The author of your article makes a lot of great points, and I’ve found that it’s more meaningful if I explain why I’m “jotting this down” while the patient is in front of me. I think it’s similar to explaining your plan of care; if the patient can understand why you’re doing what you’re doing, they’re much more likely to understand its meaning and importance rather than coming to their own conclusion.
I’ve treated an otherwise healthy 13yo boy who c/o mid-TS pain when sitting for an extended period of time at school (homeschool). His mother (and homeschool teacher) exclusively came to my clinic because we were the only clinic in the area that still had an US machine… She would define his pain for him, and even when he would answer me she would follow up with her own answer that often contradicted his response. Ultimately, I had a private meeting with the mom and explained that her son’s responses were more valuable to guiding my treatment than her own. Fortunately, she responded well enough to a brief demonstration and explanation of the current research to settle down at least long enough for me to show improvements if we did treatment my way.
1) I’d be interested objectively in his DNF endurance, effect of CS axial compression/loading, where most of his extension comes from and if he’s hinging at a level, ergonomics of his desk outfit, and mobility of his first rib ispilaterally.
2) With these in mind and the given information, you could work in some upper TS mobs encouraging extension or maybe address painful facet closing R by using techniques that open facets on L at those levels depending on irritability.
3) For me, it would really depend on his ergonomic outfit of his desk. He’s a scientist, so I would probably get more success if I explained to him more directly that anatomy and involved pathology rather than using colorful analogies to dress up what’s occurring in his body. How was his test-retest for your asterisk signs? That’d be a powerful buy-in for a scientist to see a direct cause-and-effect.
4) I’d want to know more about his PMH to determine if there’s any red flags to be wary of, but otherwise he seems like a fair candidate. If you had significant success with local mobs to the lower CS, I probably wouldn’t use a thrust as a primary technique early in treatment since you’d have some home run hitters in the wings already.
Laura,
The article is extremely serendipitous! It makes some great points that actually bring us full circle to the original talking points of this forum. The same truth for any patient is that we have to enter their world. When we exclusively speak our personal language, the meaning bypasses the patient and the intent is lost. As the article remarks, kids are not small adults and their world/ language is in constant evolution as they attempt to make sense of it all.
I love how the folks in the article utilize video recordings of the patients’ movements to get their point across. I can see how that’s a fantastic bridge between languages, and Matt maybe this is the bridge between you and your Italian patient. For kids, it could be really helpful to withhold your professional interpretation and ask guided questions to see how the patient chooses to describe the recorded movement. Now the treating PT can parallel the patient, enter their world, and begin to mold an accurate interpretation from within.