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I like the concept of “sequencing” and using kinetic chains. The exercise that Alex mentioned follows the use of global, functional motor patterns with thoracic extension, scapular retraction, and shoulder external rotation, then elevation. I like the third exercise used in this article more than the first two because it follows more of this concept. Squat and rows, step ups and elevation, side lunge and unilateral row were all examples of global exercises that were presented during our shoulder lecture and within the article by McMullen, et al. Of course, I think that isolated exercises have their place but I think the goal should be to use them to correct muscle imbalances to perform the global movements with a proper motor pattern.
I like using prone positioning for facilitating scapular strengthening, either on the table, on an incline bench, half-kneeling on a flat bench, or over a physioball. The more control and strength they have, I like to take away stability so they have to use their whole body to create the movement. I’ve even been trying out some upper extremity exercises while standing on an airex for an increased challenge.
I’m sure there are ways to incorporate external cues into scapular training. Mirror use for visual feedback is a great option for minimizing shoulder girdle elevation. What about placing your hand above the patient’s shoulder over their upper trap (not touching) and asking them to lift their arm without touching your hand?
Thank you for posting this! I feel like my RTC repair patients have been either one of two types: superstars who cruise through rehab and the others who STRUGGLE. Especially during the transition phase out of the sling. Big offenders: the patient who uses their arm way too much the second they are out of the sling and the patient who stretches too aggressively at end range rather than staying in pain-free, gentler range with the cane exercises. And it’s 100% my fault because I need to be way more assertive about restrictions and understanding how delicate these structures are. The treatment algorithm in Appendix 2 is helpful. I fully respect and follow surgical protocols but what happens when things don’t go exactly as planned? I’ll be using that in the future.
I’ve read the articles talking about how early vs. late initiation of ranges make no differences in outcomes or function and the only difference is early achievement of range of motion. At the same time, I’ve had CI’s (not Myra) tell me in the past how one of the biggest mistakes that PT’s make is to not get the passive ROM as early as you can within the surgical guidelines. I too feel as if I want to be way more conservative with these folks. What’s the benefit vs. risk ratio here? The balance is way too tipped toward the risk side for me based on this review.
Anyone else not a fan of AAROM flexion with a cane when they’ve had a biceps tenodesis?
Interesting research I came across in this review article listed in the references of Nick’s article: Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain. Phys Ther. 2010 Sep; 90(9): 1345–1355.
Physiological Response
Studies of physiological responses that accompany expectation have been reported primarily in the placebo literature. Specifically, studies of expectation-related analgesia have demonstrated associated responses, including activation of the opioid system, changes in spinal reflexes, and specific activation of the brain and spinal cord. Price et al observed a significant decrease in brain activity, as measured by functional magnetic resonance imaging, associated with expectation-related analgesia in brain regions related to pain (thalamus, somatosensory cortices, insula, and anterior cingulate cortex).
Additionally, Craggs et al studied brain activity associated with expectation-related analgesia using functional magnetic resonance imaging and observed sustained activation of regions involved in pain modulation, such as the medial prefrontal cortex, posterior cingulate cortex, bilateral aspects of the temporal lobes, amygdala, and parahippocampal cortices. Furthermore, transient activation was observed in areas of the brain associated with emotion and information processing, such as the posterior cingulated cortex, precuneus, rostral anterior cingulated cortex, parahippocampal gyrus, and the temporal lobes. Finally, Goffaux et al observed a significantly diminished withdrawal reflex, as measured by the R-III reflex, corresponding to expectation-related analgesia. Together, these studies suggest very specific neurophysiological mechanisms related to expectation at the level of both the spinal cord and the supraspinal structures.
– Karim Khan is a fantastic speaker and he definitely made a hard concept to describe really simple and understandable. I will definitely be using the explanations and diagrams he used in his lecture and lab. I was glad to also hear that he referenced the isometric analgesia study and did a great description on using isometric, concentric, and eccentric exercises based on irritability of tendons.
– In the gait training lecture, Eric used the term “drills” instead of exercises. This is such a small change of wording, but I think our athletes would appreciate this subtle change in the way we describe what they will be doing in our program.
– The metronome training was really fun and personally, I felt a huge difference with the different rates and made me realize some things about my gait too. I think I failed a bit on just changing my step rate because I was also increasing speed each time as well to try to match the cadence. Was anyone else doing both? I still felt a huge change, especially from 140 to 160, but how often do you guys increase the speed on the treadmill as well?
This is so easy to replicate in the clinic, especially since we have both a speaker system (for when the clinic isn’t crowded) and iPad’s with headphones. Having some go-to songs loaded up would be great to have. Presenting some app’s that find songs with the different rates was also really helpful too and it will be a great reference for our patients for independent training.
– Has anyone used the Askling’s H test for hamstring injuries return to sport? I thought it was an interesting concept, but I’m not sure if I would tend to use this one in the clinic. What about using the Swing test that we use for functional testing? Simpler to set up, more functional, thoughts?
– Other lectures/tools I thought were especially helpful: Ready to Run training progression, the UVa Visual Gait tool taught by Jay, the multi-disciplinary approach for diagnosis and treatment of CECS
Nick,
Thanks for all of that clarification. This is such an interesting case! It’s tough because it doesn’t quite fit cervical radiculopathy CPR, the radicular pain into the UE isn’t there, she’s in this subacute stage where it’s not acute and not necessarily in the chronic stage, but I agree with you that it seems like the most fitting with the pattern recognition. I think you did a great job in choosing the initial treatments.
I also agree that the more I read about patient expectations with treatment outcomes of musculoskeletal treatments, the more I regret not addressing this more frequently. Unlike other measures, this is something we could easily ask about and assess on an individual basis because it’s so specific to each patient. I hope we can also touch on what you all have successfully done in the case of someone who does not expect any positive outcome of physical therapy in general, say someone who is only going through a “round of PT first to be able to get my MRI”. They might show up to every session, but it’s probably going to make a huge difference in outcomes if they don’t believe it will help.
Nick,
Great case. I was reading through your subjective and I would have agreed completely on what you had as your primary hypothesis and differential list afterwards.From my understanding, it seemed to me that during her subjective, she complained of posterior and anterior shoulder pain along with scapular pain that all occurred together. During her objective (and correct me if I’m wrong), you reproduced her anterior symptoms with shoulder testing and her posterior shoulder/scapular pain with cervical testing. I’m not convinced yet that the shoulder needs to be ruled out for at least a contributing factor. I want to look at her scapular movement patterns and endurance. Was there anything out of the ordinary in terms of scapular dyskinesis or hypomobility with scapulothoracic accessory movements? With a history of hypermobility within her glenohumeral joint and I’m guessing some postural abnormalities since posture was one of your treatments?
When you tested her PAVIMs, you reported that she had normal to hypermobile lower cervical downglides but reported pain. Where during this range did she experience pain? Early or at end range?
During your treatment on the initial evaluation, you were somewhat satisfied that you reproduced then alleviated the complaint. Can you expand on what alleviated her scapular complaint since you didn’t reassess any asterisks at the end of the eval?
In terms of patient expectation, this isn’t a strong suite of mine at the initial evaluation. Sure, I give a ton of patient education and explain prognosis and plan of care during the eval and inquire about any questions or concerns, but I’m not so sure if I attempt to assess or influence expectations as much. Maybe it’s the time crunch at the end. For me, it’s more something that I look at over time. If someone is raising serious doubts of effectiveness of our treatment or showing signs of non-compliance, I will absolutely address it but really not until it comes to my attention or causing a problem, which could potentially go against my favor. I’ll be excited to discuss this with everyone!
I love the word “Empower”. Eric’s example of telling his young girl that he saw her as this confident, athletic, healthy girl really seemed to hit deep with her and her mom. The article also talks about empowering your patient with their own personal knowledge of successes in the past and embodying hope that change in possible. I think the videos are great on saying why and how exercise is great, how the body’s nervous system changes with sensitization, but I think us as therapists are going to be the link that the patient’s can make between general knowledge of the videos and how he/she and their specific story can change.
I agree with Alex in the sense that it is certainly personality dependent whether or not a patient likes a more authoritative stance, but is this more of just being confident in what you’re saying and still allowing patient autonomy versus authoritative and disregarding their perspective?
I have not personally done this in the clinic yet, but I’ve been contemplating this and maybe one of you guys have tried this already. Has anyone given this or similar videos to a patient to watch while doing any warmup/cool down on the treadmill, UBE, or stationary bike?
What a great video! Thanks for sharing. Dr. Evans has a nice presence and is easy to understand and follow along with.
One of the hardest obstacles that we have as busy individuals with jobs, families, personal responsibilities, is figuring out HOW to fit in exercise. With most of our background training as physical therapists, we have a natural inclination to get out and be active most days despite how busy we are. We know how important is it and we know how to do it. For others, it is insanely overwhelming when you know you have to be active but you have no idea how to do it. A lot of people can’t get a personal trainer due to cost and time, a lot of people are intimidated by gyms, a lot of people have no idea what exercises are actually safe and effective, and there are too many reasons why exercise can be placed at the bottom of the priority list. To incorporate something into daily life, it needs to be important, manageable, and effective. We can’t force anyone to do anything, but we can be an example ourselves and emphasize how exercise can be all three of those things.
Why I love this video is that it breaks down how relatively little time each day we can dedicate to exercise daily and how huge the effects can be. 10 minutes, three times a day. So much more manageable than committing an hour, 3-4 times a week.
To answer your question, for some of our at-risk or chronic patients maybe there isn’t a better exercise program over another. Just getting out there and doing something active for 30 minutes a day (in 10, 15, 30 minute intervals) can reduce your risk for some scary consequences but also IMPROVE your current quality of life. Whatever it may be: walking, jogging, cycling, stair climbing, dancing, tennis, golf, cardio equipment, swimming, yardwork, yoga, crossfit, exercise videos, stretching, just something to get out of sitting can have great effects on the mind and body.
Certainly we see lot of risk factors such as obesity, HTN, hyperlipidemia, smoker, etc. in our clinic, but I think one of the biggest trends we see is anxiety and stress. I’m so glad he added that in there because that’s something we can all relate to. We’re even seeing kids of high school age coming in for neck/back pain because of how much stress they’re under with studying and getting into college. I have a couple high school females on my schedule that fit this trend and whom I want to show this to now.
Oksana, it sounds like you guys do great work with fitness screens and getting the word out there for our role. Cheers to that!
How do you determine the certain patients and certain injuries that have an increased risk for prolonged/recurrent disability? Who makes that call and how do we pinpoint those people out in the community without waiting until they become chronic?
What would you do in this case? A 28 year old male healthy, fit accountant has a back spasm after a workout. He usually does power lifting with his buddies but hasn’t had any real training with form, mechanics, etc. He sits at a desk for 10-12 hours a day, then works out intensely at night. He deals with the muscle spasm for a few days, then gets on with his life and doesn’t change anything. Then, he gets another back spasm a few weeks later with the same workout. Has to deal with it again that puts him out for a few days again.
Is there a place for us here? Would you agree that 1 or 2 sessions of looking at mechanics and form would be beneficial for him, maybe looking at his work habits contributing to the problem?
Nice topic Oksana! Thanks for sharing your case, this has been really helpful. Can’t wait to see the Reverse McMurrary’s, mind blown.
Yes, I agree with you guys that a louder landing should have correlated with less hip excursion and therefore less force absorption through the lower extremity joints. BUT, in this study the participants were TRYING to create a louder sound. Therefore, doesn’t it make sense for a person to lean onto that side to create more force into the ground? Like the authors said, the participants were not aware that they were measuring ground reaction forces but trying to create the loudest sound they can. I think this makes the “louder” trials negligible. The more important differences are between the normal and the quiet, where we saw more hip, knee, and ankle excursions in the quiet landings.
“However, we must of course ensure that patients are moving through joint excursions in the proper plane and with proper motor patterns, or else the risk of injury may indeed increase. ” On point Nick!
I think gaining dorsiflexion will also be crucial for decreasing further injury. We can’t use what we don’t have. Joint mobilizations, STM, PNF, MET’s, flexibility exercises would all be great to use to decrease any torque or compensations up the system that could compromise the irritated structures.
I wouldn’t consider his age to be an excluding factor. I don’t think that age changes adjustment patterns during tasks, but presence of lower extremity injury does. Also the fact that he doesn’t even have the ankle dorsiflexion range of motion that was reported as average excursions for both the quiet and normal trials.
This got me thinking about a patient I just evaluated last week – mild low back pain that I hypothesized as low lumbar facet dysfunction, came in through direct access because he had some family members who had success with other PT’s our clinic. He presented with pretty low level deficits and had this pain for only about 4 weeks, and is getting much better anyways on his own. But what was so awesome about what we could do was the fact that he worked right upstairs, so we went to his office during the eval and problem solved right there what could be contributing to his back pain (monitors, keyboard, mouse all off to the left). With some other education about self-management and treatment using manual therapy, I felt like that was the most successful eval I had all week, month, etc. because we addressed causation and self-management strategies right off the bat. Let’s be honest, this doesn’t happen often but I wish so bad it was more the norm!
1. I suspect the current guidelines are based on the age-old theory that most back pain gets better on its own, therefore no intervention is necessary and patients will get better by staying active and with time. “Self-care” will be sufficient for 6 weeks, then if that is not successful, then other conservative treatment options can be taken. Yes, I do think this is appropriate in some cases like first offenses that are mild in nature and non-neurogenic. With that said, there is a reason why the back pain initially occurred and I think we have a lot that we can offer patients in terms of prevention of future occurrences, body mechanics, exercise form, and self-management strategies.
2. With large systematic reviews, it’s hard to be homogeneous when it comes to concluding an overall treatment effect without looking at the specifics of the articles included in the review. That’s one of the only problems that I have with this article is how much variety there was within the treatments that were listed for physical therapy. Passive treatments including ultrasound/TENS, active exercise, manual therapy, functional training, stress management, some articles didn’t even list what treatments they included. Even listing “exercise” as one of the treatments is vague and one of the things that successful physical therapists do well is provide a very specific, individualized approach for exercise prescription. General exercise vs. specific, functional exercise prescription could make or break a recovery. Maybe this is somewhere we lose the real, significant effect on function and pain.
3. Knowledge and presence in the community are huge barriers. I don’t think the general population knows what we have to offer or even knows that it’s an option to come to us first. It’s frustrating to say the least. Direct access is so important to progress our field and to make sure we keep pushing for our role as musculoskeletal and movement experts. On the other hand, so much of our credibility of our treatments is based on literature and systematic reviews like this one can be shared to compile the trends in data. More studies can create more support, then can create change in practice patterns.