[Laura Thornton]

Here are two surveys done internationally within the last decade on the topic – where do you stand?

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[Laura Thornton]

I’ll leave you guys with this – from the Journal of Pain just published.

Thoughtful review on the multi-dimensional contributions to chronic TMD.

Always a good idea to review journals other than PT specific – allows us to think from a bigger perspective so we can think, communicate, and care more comprehensively.

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[Laura Thornton]

Nice discussion – let’s keep it going.

Here’s another library builder for your review and reference.

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[Laura Thornton]

Thanks for your input so far guys – there’s three different points of reference for her timeline of symptom development and the details about each will help determine the relationship between them. I think a good, detailed subjective is pretty crucial in this case.

Thanks Cameron for mentioning speaking with her dentist about her case – that would be huge in helping understand her history, medical perspective, and specifics of the dental procedure.

There was a few mentions on the psychosocial impact of her history that could shape her prognosis and treatment – what would you ask this patient to find out more about her coping mechanisms, self-efficacy, and potential to respond to treatment?

[Laura Thornton]

Great input guys! I appreciate the priority on activity modification and education, which is key.

Let’s talk exercise specifics – there’s a lot of great approaches here (neurodynamic, self-mobilization, general strengthening, stabilization of the CMC complex).

What do you guys think about these two articles from JHT? They might shed some light on ideas for what to do with these patients.

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[Laura Thornton]

Well done with the thorough differentials.

Thanks for the reference Casey – I attached the article link.

I think this article is a great example of bridging the gap – can we take a controlled, laboratory-based study like this and make any connection to our patient care.

Any additional thoughts about the study?

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[Laura Thornton]

Nice start with the compilation of subjective and objective lists – there’s obviously a lot of structures at play.

Let’s say his pain is in his left hand and he is a right dominant player. Denies pain in his elbow, shoulder, or neck. Initial MOI happened last spring when he swung and hit a tree root with his club. He initially played it off, pain subsided within a few days, but has noticed pain and mild localized swelling returns throughout the year if he’s playing tired, at contact when he hits a ball off-center, if he tries push ups or chest press at the gym, or if he tries to pick up his golf bag with his left hand.

Let’s get more specific with the major diagnoses you guys listed – how would you differentiate between a TFCC injury and a fracture, ligamentous injury, and/or ECU involvement?

[Laura Thornton]

Here’s one of the features in PT In Motion this month to go along with the discussion of treating young athletes:

http://www.apta.org/PTinMotion/2018/11/Feature/SmallAdults/#

Have a read and share any discussion points you think might be relevant when communicating with this younger population.

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[Laura Thornton]

There seems to be a debate at play on whether there is a structural vs. neuromuscular component to your “low hanging fruit”, since there was no report of obvious training errors at eval.

I would think about his fear of medial joint line narrowing.

How could your approach to his initial treatment (including communication to him) either validate this fear into more avoidance/passive strategies or give him more positive active approach to his goals?

Would love an update when you do a run analysis with him.

Here’s a food for thought article discussing running economy with different factors.

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[Laura Thornton]

Hey Katie –

– Seems like there was a pretty significant chemical inflammatory component to his pain initially, with his response to the prednisone dose pack and quick decrease in pain over the past week. Could also explain his initial negative response to distraction in both flexion and extension. Does this initial response to distraction on day 1 deter you from looking at unloading strategies in the future?

– How did you modify/progress the UPA treatment from session to session, including grade, level, and positioning? Specificity with mobilization can help guide your manual treatment to gradually improve joint mobility and enhance what he can do actively during exercises.

– The resolution of tingling in the ulnar nerve tension position could potentially be a response similar to the shoulder abduction test for cerv radic. I wonder if this could be useful in educating him on arm positioning to relieve symptoms during the day, as you are building postural strength and endurance exercise program.

– Attached a recent review on clinical diagnostic testing for cervical radiculopathy in Spine. Food for thought when building differential diagnoses lists.

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[Laura Thornton]

Hey Katie –

You’ve got some great information from the evaluation to start treatment.

I would add a few things:

– There is a tendency to group all neurodynamic testing into the median-biased test for the “catch-all”, however when you have such a specific route of pain along the posterior arm, I would test ulnar-specific ULTT to really rule out the neurodynamic component (especially if the posterior arm pain is reproduced with cervical flexion quadrant AWAY from the side of pain).

– The fact that you were able to reproduce his pain with compression, then immediately resolve it with distraction, is a powerful buy-in and educational tool. From this, I would go into teaching him self-distraction techniques for home to perform when he’s sitting throughout the day, rather than “stretches” (is flexibility really the issue?), then also use it to talk about load-sensitive tissues and positioning techniques to decrease pain. Manual traction is a great technique to perform during nerve glides, joint mobilizations, active movements, etc as he continues to improve.

– It’s interesting to think about biases with this patient because there are several reasons why you would classify this patient into a “mechanical” treatment classification (painful and hypomobile segments, pain with extension/quadrant, clear neuro), therefore go right into manipulation/mobilization, because we think mechanical = joint mob/manip. But, by doing this, you can at times bypass the most important information that you got from your eval, which for him were his load sensitivity and response to compression/distraction. Classification of clinical presentations are an important piece to the puzzle but you also don’t want to miss out on other asterisk signs that could potentially be more functionally meaningful at the start.

Sorry I have to miss journal club this month but looking forward to hearing about the discussion and continuing on the discussion board.

[Laura Thornton]

Here’s the objective findings from the evaluation on Day 1:

Neuro screen:

Myotomes – hip flexors 4/5 B, rest of LE myotomes 5/5
Dermatomes – intact to light touch bilaterally expect for lateral thigh reports “tingling” to light touch (several inches below greater tuberosity starts, travels down to approx. 3 inches above knee joint)
Reflexes – 2+ throughout
UMN – Babinski negative, ankle and wrist clonus negative, Hoffman’s negative

Sit to stand transfer: patient reported immediate pain in posterior thigh B upon transfer, immediately resolved upon standing after 5 seconds

Static standing posture: increased lumbar lordosis, anterior pelvic tilt, hypertonic lumbar PVM

Gait: wide BOS, right uncompensated trendelenburg, significantly limited hip extension B, denied pain during 30 second walking assessment

Lumbar Flexion AROM: increased thoracic flexion, minimal reversal of lumbar lordosis. Fingertips reach ankle joint with knees in full extension. Posterior pelvic shift. Pain reproduced in bilateral posterior knees upon first 25% of range, then resolved into further flexion. Pain returns upon last 25% of extension into standing upright.

Lumbar Extension AROM: 25%, minimal segmental extension through lumbar, most performed with anterior pelvic shift. Painfree, with the exception of twinge in posterior thigh B upon return to neutral. Sustained with overpressure into extension painfree.

Lumbar Sidebending AROM: 50%, minimal segmental motion through lumbar, painfree with OP and sustained pressure B.

Lumbar Extension Quadrant AROM: 50%, painfree B

Slump Test: Negative for any reproduction of symptoms in full knee extension with slight Achilles tightness with added DF.

Straight Leg Raise Test: Negative for reproduction of symptoms B

Lumbar PPIVMs/PAIVMs: hypomobile into flexion PPIVM at L3-4, L4-5, L5-S1

Hip Extension PROM: -40 degrees of hip extension (knees bent), -34 degrees of hip extension (knees straight)

—

1) Knowing the subjective and objective data, what are your conclusions about this patient?
2) Anything particularly surprising or that does not fit your hypothesis?
3) What would be your primary treatment objectives for day 1, inc. education?
4) Would you have done anything differently or added more evaluation to what I did on the initial eval?

[Laura Thornton]

Thanks for responding guys!

I agree on performing a full neurological examination and keeping vascular claudication on your differential list.

Speaking of this, what are some key risk factors, quality of symptoms, and agg/ease factors that you can use to differentiate between vascular and neurogenic claudication?

Sarah – the symptoms between the right and left LE are variable. He will at times have pain in both legs, sometimes in the right, sometimes in the left, and the intensity of the pain can vary from 1-2/10 to 5/10. Usually if he experiences pain in both legs at the same time, the pain will be in the same area (either posterior thigh, or posterior calf).

I also agree with presence of yellow flags. His only exercise post-op was a walking program, but is unable to perform due to his pain, so you could imagine his frustration and desperation to get this taken care of. His only treatment approach so far has been passive treatments (cortisone injections, TPDN) without any improvement in symptoms. Quote from subjective, “all I want to do is get back into walking”. How would this direct your initial treatment or general POC?

Remember – the paresthesia on the RIGHT lateral thigh started after the LEFT anterior approach THR. It’s interesting to think about this as both a differential diagnosis, but also for patient education to improve his understanding of condition.

Tyler – He had an anterior approach on both hips and is not under any specific dislocation precautions at 10+ weeks post-op (right hip). My experience is that there is some controversy over precautions s/p anterior approach, however generally there is a lower risk of dislocation associated with the anterior approach THR. Each surgeon is different, but generally want to avoid forceful end range extension/ER.

Any other thoughts before I post the objective examination findings?

[Laura Thornton]

Here is the body chart for reference.

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[Laura Thornton]

One thing I have come to realize after treating a couple patients this year with a larger psychosocial piece is that you can’t expect people to understand pain in two visits. Understanding pain is a hard concept and it takes time. You have to layer in pain education with other treatments as they gain trust in you as their practitioner.

That’s why the first several visits are crucial for patients to believe that you understand them, you are listening, and you have compassion for them and their story. Even indirect things like eye contact, body language, and gentle handling skills are huge. I try to make a point to pay close attention, let them speak, and then say something along the lines of “I can’t imagine what you’re going through, it takes courage to show up here and continue to try and get better, and I am going to try with all my power to help.”

Assess, treat, reassess is a core concept that we use, but those who have a big fear component and poor coping strategy, I like to use it to decrease fear of the untreatable and to give back a sense of control.

I also use Lorimer’s snake bite story quite commonly to tie in how the brain uses memories, emotions, and environments to perceive a threat/non-threat. I like to point out the optimistic view of the human body being adaptable and learned, because that what makes us so much better than machines, and as much as our body has become sensitive, it can do the opposite and change back the other way.

It’s a tough conversation to have when the patients who are adamant that they require an unnecessary MRI, surgery, or further referral. I like to keep in mind that the patient has right to make the best informed decision on their care. It’s important to acknowledge their concerns, lay out all the indications for further referral, and explaining how they fit/don’t fit in these indications. This would include what the MRI, surgery, or referral would NOT provide or show, and with a benefit/cost ratio, give them my opinion on whether they should or should not. Relate all the current research we know on unnecessary referrals back to their situations so they have the facts and can be part of the decision making process.

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