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I chose to review the 2019 article by Crossley and Cowan, which echoed one that I found when a student in my first clinical rotation. At the time I saw I has a patellofemoral referral coming for an eval, and I wanted to confirm what the evidence showed was helpful. I was surprised to see that hip strengthening alone or in combination with quad/VMO tailored training was superior to quad focus alone. I have continued to address strength imbalances in the hips with this patient population from day one.
In the same clinical I remember my CI always using the magic number 3/10 for a target VAS pain score. The patients seemed to respond well to it, with less fear avoidance and a sense of control over the therapy progression. I continued to use this idea as well, but honestly never inquired into where he got the magic number. I like idea of continuing this target/limit with progression of functional loading (for various conditions) and using it as a tool to show patients that they can respond well with progression of forces, while taking care to avoid “pain” but allow “discomfort” to discourage pain inhibition, improve self efficacy, and promote increased adherence to the HEP.One recent example I have for when I decided to approach a patient complaint with training to alter biomechanics is for a patient with greater trochanteric pain/glute med tendinopathy with a very apparent hip drop during gait.
Admittedly, I did not make this decision with a specific research article in mind, but based the decision on my clinical experience and knowledge that this condition is said to be triggered by repetitive compressive or tensile loads or poor lumbopelvic or LE mechanics. This is essentially how I described my reasoning for hip strengthening, gait training, and focus on pelvic control/stability in SL stance and gait. Looking back, in this situation I stand by it, though see where relying on intuition or general knowledge base could get tricky in situations.
In regard to the discussion above, while general strengthening may not lead to the improvements expected in the examples, the improvement in the strengthening groups may be explained by the related improvements in neuromuscular control, proprioceptive gains from the repeated exercises, and or conscious or unconscious learned pain free (or reduced) movement patterns. Does this have merit, I would think/hope so, but again no specific research to site off of hand.
Response for article below to come shortly! can’t access it from the text field.
:)The articles below may help to put this discussion topic into perspective. Please take the time to read one of the articles about PFPS (although I would recommend them all as they are very short). What are your takeaways and how might you apply this to clinical decisions in the future?
This article tells me that at the time of it’s writing, there was not a lot of high level evidence behind these protocols (at least not full text available in English). It highlights the fact that whether RTSA or anatomical TSA there is a lot of variability behind protocols. It highlights the common concern for subscapularis tendon integrity, as well as potential stress fractures. Essentially, take them with a grain of salt, consider the anatomy involved, review the op report if available and consider the involved structures and the stages of healing when progressing your patient.
This sounds great! I was just discussing how I would benefit from more TMJ, concussion, and vestibular training.
Thanks for putting it together!1. I feel that I am good with certain aspects like building rapport, performing a skilled examination to offer an accurate PT diagnosis, and explaining the reasoning behind my exercise selection, but could work to make the patient feel more involved and in control sooner in the course of care. Many times, especially floating between multiple clinic locations and sharing a case load, I’ll notice that patients begin to rely on the in-person sessions for the maximal benefit and await specific progressions with advancement of the written home exercise program. When I take the time to explain that anything we do here can be done at home (within reason and depending on equipment) and encourage the patient to stay active they seem to be more involved and take on a level of personal responsibility for their progression of care. Further, I find it very useful to reference the previous documentation from another clinician and ask about the response to any new exercises or differing approach. Patients respond well to this, recognizing that I am staying informed on their progress and working to seamlessly progress their care, even though the appointments may be split between multiple providers.
3. In one recent patient interaction, I had a patient that was very discouraged by their recurrent pain and seemed to be becoming less engaged in their sessions. They felt that the pain was better after sessions, but that they felt a bit helpless when it came back outside of the clinic, and they could not get manual assistance. When I broke down the manual therapies and progressions, showing the patient modifications to achieve similar results at home with positioning and self-myofascial release techniques, they expressed a sense of relief and the patient’s demeanor changed. They developed a sense of empowerment and hope for self-management outside of sessions.
Sometimes when we are very busy as clinicians, it can be hard to hit all of the marks. To make sure the patient is informed and aware of their diagnosis and prognosis, display sincere interest in their situation and their progress, teach them the skills they need to be able to continue progressing and address the symptoms outside of sessions, and eventually empower the patient to self-maintain after discharge is more of an art than a science, but this article does a good job of breaking down the aspects that seem to be important to the patient, and allow me to have markers to address throughout the progression from evaluation to discharge.
This topic is certainly one that I have come across many times already. As you have seen from my recent posts, I have recently been working with a patient who has been fed some very “unhelpful” information about her imaging results, which seemed to heighten her anxiety and with that her symptoms.
These articles both touch on some helpful information regarding patient needs and desires, as well as how they interpret the diagnosis they may hear from their clinician. At first glance, these two seemed slightly contradictory due to one saying patients desire to have a specific confirmatory diagnosis, even though current evidence suggests against imaging, and the next saying that these diagnoses confirmed on x-ray like disc bulge, degenerative disc, arthritic changes lead to negative interpretations with lower expectations and the sense that more drastic measures may be necessary to recover. However, the ideas can be useful in formulating a method of communication that is likely to lead to a more positive expectation. Some patients may respond well to the education that the imaging results are less helpful, and that PT can effectively diagnose and treat their pain as effectively, and with less expense and risk, than surgery or medication.
I do find it challenging to attempt to reshape the patient’s mindset when the doctor or another clinician has already used unhelpful language and told them they have terrible degenerating discs, advanced arthritis, or disc bulges at various sites. In these cases, the patients like a breakdown of what that means and what our actions in physical therapy do to improve it. They also often ask, “does this mean it will just keep coming back?”, and “if it’s degenerating, is it going to get worse and worse”. Those encounters seem to take a bit more time for patient education to get buy-in. In other cases, the patient may not be able to get an MRI unless they have had PT first due to insurance, and I have found it less challenging to elicit positive expectations in the first few encounters in these cases.
I wish we had a successful campaign in this country about the benefits of staying active with low back pain, and I am surprised we haven’t had a large-scale advertisement or campaign to educate the public. There are many resources on the topic, but when I google “back pain relief” the first thing I see is a Web MD article with 14 ways to relieve low back pain, where PT is #6 and the leading remedies are drugs, postural correction, and sleeping better. While some of these are beneficial in many cases, most of them do not fix the problem and several don’t even promote blood flow or healing.
As for a personalized approach. I think patients are correct to desire this, and this can be accomplished based on subjective history taking and examination results. Putting the pieces together, for those without imaging results, careful education on the role of PT in diagnosing and treating their impairments, effectiveness of PT in treating back pain compared to other treatments, reasons why imaging may not be necessary or beneficial in addressing impairments, how we can make a tailored treatment plan based on their specific situation and symptoms, and that we are able to progress the plan or make changes along the way as needed seems to be key in getting the ball rolling on course. For those who already have imaging/and or already have negative expectations, the work is a bit harder, but the biggest difference would be addressing the imaging results, teaching them that they may have had these changes years before having any sensitization in the area, and elaborating further on the prevalence of the same imaging findings in the general population coupled with education on tissue sensitization and potentially more pain neuroscience education may be beneficial.
Please see attached
As a personal trainer and group fitness instructor as well as a PT, I have seen a lot of this one! I try to be sure with patients and clients to program a bit more conservatively (at first) for those that are deconditioned, but I think the biggest benefit is the education on letting the first few sessions guide intensity and volume, and that a bit of DOMS is expected, but should not be so painful that they fear coming back.
I think its great that you used this example because it is something many PT’s might not think to explain to their patients. We won’t always get the dosage right on the money the first visit, but letting the patient history and activity levels guide it and being sure to educate the patient on acceptable levels of pain and/or soreness during and after sessions has really helped in my experience.