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Like Scott said, I have been co-treating this patient and I cannot stress enough how important the psychiatric referral will be for him. The more that he tells us about his life events and how they coincide with periods of increased pain or injury, this may be one of (if not THE) most important component of treatment. He was hesitant at first to the idea, but seems to be coming around now after this past session.
I don’t want to underestimate the power of manual therapy for this patient either, for both addressing the physical tightness around his cervicothoracic region and hypomobility in both upper cervical and thoracic regions, as well as provide opportunity to discuss pain education, importance of consistent walking program, progressive movement with left arm, and rationale for our other treatments. It has definitely installed more trust from him in us that we are listening to his story and what he believes is helpful for his pain.
I like the ideas of tactile stimulation that you guys have suggested, including the compression shirt and aquatic therapy. I think stressing to him the importance of using his arm for functional tasks will be key for him, like using his left arm for automatic motor patterns like light switches, buttoning shirts, arm swing during gait. He’s a PE teacher and former baseball coach, therefore we might be able to find familiar or automatic movements associated with either that he could practice to assist with plasticity and cortical re-organization.
Thanks for sharing this article Nick, and yes, sorry for the very late response.
This diagnostic test reminds me of some of the aspects of external rotation lag sign of the shoulder, minus the proximal stabilization.
I have a hard time believing that a lot of these individuals will be able to achieve the full testing position, especially the 10 degrees of hip extension needed. Hip extension is so commonly lacking in those with hip pathology. I’m not convinced that this test would be more useful over an active movement from neutral into abduction/IR/extension and assessing associated pain during the test.
I do appreciate the added proximal pelvic stabilization as a piece of the test, however I would add it might be beneficial to repeat the test without manual pelvic stabilization, to assess gluteus medius role in both functions.
I would proceed with caution with using this test in isolation for gluteus medius/minimus pathology, at least for physical therapists. There’s no distinction between the spectrum of pathology, from atrophy, tendinopathy, or rupture. The authors claim that based on positive test results, a referral to a surgeon for an endoscopic procedure would be appropriate, which I think is premature, due to limited correlation between pain and disability.
Thanks for posting Nick.
1) Are those two things so mutually exclusive? Isn’t the point of this article to say the exact opposite, that each component should be integrated equally?
2) I understand where you’re coming from with the question, “Is it simply confusing?”. I agree and disagree. The previous framework breaks it down easily, generalizing the three main components into evidence, patient, and expertise. This is a easy concept to learn and teach. But, the authors are correct that it doesn’t include so many important factors like the differences between levels of evidence and including boopsychosocial as an overarching theme. But I feel like a big rationale for this framework is for students and teaching tools, so if you were a new student who was starting to learn this framework to practice, would you get overwhelmed with this new model that they are presenting and need to start with a more basic framework? Its the same with learning levels of evidence. As clinicians who routinely see and practice every day, we more readily can appreciate case reports and detailed studies for our own application. But if you don’t have a reference to relate the case studies to, I understand why the generalized RCTS and SRs are important to begin with. So, I’m playing the neutral card, I understand the importance for both models.
I’m not sure if you would be able to rule out neurodynamic involvement yet, especially with the history of previous strains (with no treatment), possible scar tissue, and close proximity of the structures. If unsure, I would perform a neuro exam too to be sure of any involvement of nerve injuries, and nice idea by Alex for the reverse Slump. If there is a component of neurodynamic involvement, and not addressed, I would think that it might affect overall pain levels, strength gains, and predisposition for further injury, therefore delaying recovery process and ability to progress through exercise program.
Does anyone recommend continuing to monitor SLR/Slump/neuro throughout the recovery process to ensure that scar tissue doesn’t affect nerve mobility?
Alex >> I like Heiderschiet’s article talking about both the theories on effect of eccentrics on scar tissue development:
“An alternative explanation is that the use of early mobilization limits the residual adverse effects of scar tissue formed early in the remodeling process. Early mobilization has been shown to promote collagen penetration and orientation of the regenerating muscle fibers through the scar tissue, as well as re-capillarization of the injured area.”
And the effects in terms of the ability for the muscle to accept more tension due to a shift of the length-tension relationship:
“Scar tissue is stiffer than the contractile tissue it replaces, and thus may alter the muscle-tendon contraction mechanics. Specifically, a decrease in series compliance would shift peak force development to shorter musculotendon lengths. In noninjured subjects, the performance of controlled eccentric strength training exercises has been shown to facilitate a shift in peak force development to longer musculotendon lengths. Therefore, eccentric strength training following a hamstring injury may effectively restore optimum musculotendon length for active tension to normal, thereby reducing the risk of reinjury.”
Good point between tendinopathy vs. strain. There are certainly overlap between both, but there’s a few different important aspects I would consider:
– Lack of inflammatory process with tendinopathy vs. acute tear/strain of hamstring muscle belly including edema, hemorrhage, etc. I would think that strengthening the tendon to allow greater tolerance to load vs. promoting remodeling of muscle fibers would need to be kept in mind.
– Load, Load, Load for tendinopathy. Certainly strengthening is key for both conditions, but I wouldn’t tend do perform manual therapy and other aspects of care that I might add for a strain/tear.
Aspects that overlap: assessment of neurodynamic involvement, agility training, lumbopelvic stability, and progression of resistance exercises incorporating eccentric lengthening when appropriate and pain-free.
To answer your question on instability features of our patient,
For upper cervical instability features:
– Forward head posture
– Intermittent ringing in the ears
– Minor trauma to neck (surgery)Denies headaches, dizziness, or other cranial/VBI symptoms.
For segmental instability:
– self-manipulation temporarily relieves symptoms until feels “tight” again, especially with prolonged sitting postures.
– location of pain (R U/T)A lot of the research for Grisel’s syndrome are case reports of patients within a very acute period after surgery, with minimal information on long-term results or outcomes. Since she is four months out of surgery, how would this change everyone’s view on evaluation and treatment? I agree with you all that I would certainly continue to monitor all signs/symptoms and proceed cautiously, because of this lack of evidence and potential for serious consequences.
Thanks for sharing Oksana! Looking forward to discussing this study at journal club. I think it’s great that you are trying to be as specific as possible with the type of rehabilitation program for him and adding in trunk/pelvis stability training.
You mentioned that you provided him with a verbal cueing of decreasing forward lean during running. What is your rationale for giving him this cue?
I think mapping out a return to run plan would also be an important component to discuss with the patient. The article by Heiderscheit et al from 2010 talks about progressions from stage to stage for hamstring strains, with criteria to progress to return to sport. Without knowing the exact location and extent of the injury, this could help with planning out what he can expect through recovery and keep you guys on the same page. Have you guys discussed a plan for this yet?
I love this article for the references back to hand/wrist positions on the club and effects of ball contact relating back to these injuries/conditions.
The authors also made interesting points about the differences between amateurs and professionals, whereas the professionals tend to have higher swing speeds and greater impact forces, as well as higher tendency for overuse injuries rather than acute.
I would even suggest taking fatigue as a factor as well, where swing mechanics and efficiency would be more impaired at the end of rounds. The same with incline, where wrist positioning at contact might also change when hitting from incline/decline positions. In addition, the concept of hitting “downward” is usually associated with irons, which is different than hitting with a driver in which players would tend to hit up/outward from a tee.
Along with Kyle’s suggestions for treatment approaches, I would suggest a swing analysis with different clubs, incline/decline changes, and possible effect of fatigue to symptoms. This is where I also think communication with the player’s pro/coach would come into play, comparing where and when the player has symptoms to if mechanics or grip positions would need to be modified.
Thanks for sharing AJ. Great reflection paper. A few things I took away from this article:
Section 3.4.3 >> How many different kinds of touch we provide to the patient! You have never really quantify how much we do touch our patients, not just with specific manual techniques, but with assessment, guidance, demonstration, greeting, goodbyes, etc. It can have significant effects, both peripherally and centrally.
Section 3.4.1 >> “In addition in physiotherapy, the administration of an overt treatment by a mirror feedback was proposed as an effective strategy in chronic LBP (Daffada et al., 2015). Indeed, patients that looked at their back when moving during exercises reported less increase in pain and a faster resolution of their dysfunction (Wand et al., 2012; Diers et al., 2013).”
I need to do this more! I use all the time for retraining in the gym for mechanics and form, but not for placebo effect or to gain a sense of control of the movement. Even encouraging patients to use mirrors at home when performing the exercises could be beneficial. Does anyone use this strategy a lot for this?
Section 3.3 >> There are certainly some ways I can improve on my communication with patients and I admit, when times are busy at the clinic, sometimes adequacy and “this will do” attitude takes over. For instance, when I am writing home exercise programs and I’m in a rush, the sheet won’t give as many specific instructions or I won’t have time to include pictures. It definitely makes me step back and say I need to shape this up because this is the communication that you have with your patient 95% of their time when they aren’t in the clinic.
By the way, I’d be curious to see in person what slanting 90 degrees towards a patient would look like…
Wow, that’s fantastic! Nice work.
Do you think that the strength and mobility deficits would be addressed with an independent program and fitness regime? He has returned to work, running, beginning swimming, ADL’s, and is painfree. If he doesn’t require supervision for his program and you don’t think he needs more manual therapy/direct physical therapy, and he feels like he has met all of his functional goals, then is it possible to decrease frequency of visits and see him 1x/month for progression and guidance? If you think that he still requires supervised PT and needs direct treatment, then I would press on. If not, I would begin to transition.
4 months out and we are well into the remodeling phase of healing – which takes time. Dislocation can be a big trauma to the shoulder complex and I wouldn’t be surprised if you see more of a plateau when you get into the later stages of healing. Add in his history of recurrent subluxations of his right shoulder (did we confirm that he has general laxity?), I would think he would need more time to gain motor control and strength but this may be something that he could do on his own without consistent PT sessions.
Can you be more specific on the moderate mobility and strength deficits that he still presents with? Where is he currently in regards to functional return to work, daily activities, running, and swimming?
The results of this study don’t surprise me. I have difficulty relating the FMS screening movements to the demands that these men and women are subjected to. I like the comprehensive and global movements that comprise the FMS, but to me it’s no wonder why the ability to predict injury is low because they aren’t actually screening the tasks that they need to be able to do.
I am not going to pretend like I know what specific tasks these men and women do every day (my best guesses is running, jumping, endurance training, heavy lifting, shooting, climbing, etc.). I could see how someone who has a really low score (5-9) would warrant further evaluation, but why not do biomechanical screening and analysis with those specific tasks?
“This may suggest that the quality of movement is not the primary indicator of the injury risk and that perhaps other factors such as pain occurrence are more strongly associated with the risk than the actual composite score.” I think this is definitely more of a valid conclusive statement.
Nick >> this was an interesting article on predictors for chronic ankle instability after primary ankle sprain. They speak on different movement tasks and biomechanical faults that might predict sustained instability and repeated injuries:
Recovery From a First-Time Lateral Ankle Sprain and the Predictors of Chronic Ankle Instability: A Prospective Cohort Analysis
Cailbhe Doherty, PhD, Chris Bleakley BSc, PhD, Jay Hertel PhD, ATC, Brian Caulfield, PhD, John Ryan FCEM, FRCSEd, FFSEM, DCH, DipSportsMed, and Eamonn Delahunt, PhD
The American Journal of Sports Medicine 2016; Vol. 44, No. 4: 995-1003