[Laura Thornton]

Here’s a recent review by Jenny McConnell on the treatment for infrapatellar fat pad and plica injuries. She describes a detailed anatomic and biomechanical view of the infrapatellar fat pad and synovium. She also talks about the IFP taping technique that unloads or “shortens” the tissue that Eric presented on. I’m not sold on the involvement of the infrapatellar fat pad in her case, do you guys think it would be worth trying on my patient anyway due to the close relationship between the two structures?

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[Laura Thornton]

Those are really good points and I can appreciate keeping patients on ADs longer to facilitate normal gait mechanics. Myra and I have incorporated this with a few patients and have seen really good results. Once the patients can understand the importance of good mechanics and neuromuscular re-education, they come around to keep the AD a little longer.

It’s interesting in the article they state that the conservative precautions can actually be counterproductive in recovery and they can increase the risk of dislocations due to decrease movement in the initial stages.

I found a few articles that might be of interest. First, a retrospective study on dislocation rates with posterior approach THA for just 4 weeks:

Minimal invasive posterior total hip arthroplasty: are 6 weeks
of hip precautions really necessary?
Schmidt-Braekling T, Waldstein W, Akalin E, Benavente P, Frykberg B, Boettner F.
Arch Orthop Trauma Surg. 2015 Feb;135(2):271-4.
http://link.springer.com/article/10.1007%2Fs00402-014-2146-x

They found a 1% dislocation rate out of 797 patients (total of 8). A few were caused from trauma and a few were caused from sitting on a low surface in the home.

A systematic review also found 2 RCT’s looking at anterolateral approach. Unrestricted protocols (without precautions) found no dislocations and better/faster recovery. I attached the tables.

Are Hip Precautions Necessary Post Total Hip Arthroplasty? A Systematic Review
Barnsley, Barnsley, Page.
Geriatr Orthop Surg Rehabil. 2015 Sep;6(3):230-5
http://www.ncbi.nlm.nih.gov/pubmed/26328242

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[Laura Thornton]

I recommend reading the section in the article I attached:

“WHAT FORCES PROMOTE THE OVER– USE OF IMAGING
IN PATIENTS WITH LOW BACK PAIN?”

[Laura Thornton]

This discussion board is highly entertaining. Once again, more substantial evidence of the downfalls of MRI imaging for this subset of patients and although it’s been supported in the guidelines of the American College of Physicians and American College of Radiology since 2012, why is this still a prevalent issue?

I don’t know about you all but I have never seen epidemiology reports on MRI imaging.

What is happening here? There is no explanation on why some MRI reports had the epidemiology data and some did not. Including this data had a clear, significant correlation with higher rates of narcotics use, re-imaging, injections, etc. Was this the radiologist’s decision to include the data in the MRI reports? Seems like it would be a pretty easy thing to place on every report regardless, since the printed statement had clearly profound effects on treatment in this retrospective study. WHY this effects treatment is another issue.

I say as clinicians in every field (medicine, physical therapy, nursing, etc), let’s all get on the same page here to prevent catastrophizing and help this subset of patients get better.

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[Laura Thornton]

This is interesting…

PSEQ is an outcome measure that is based on efficacy and “how much effort people will expend and how long they will persist in the face of obstacles and aversive experiences.”

Focused on what they are able to do in spite of their condition, not focused on PAIN and DISABILITY caused by the pain.

Nice concurrent validity with the PCS and PHQ-2 in this study. Useful to have something on file if frustrations run high.

[Laura Thornton]

Great presentation today Sean. I have a hard time reflecting on these types of patients and as to what kinds of things I could have done differently. I appreciate how much you are trying to find the best approach for him and looking into both research and expert opinion on the matter. This is a challenging case for not only the presentation but the patient-clinician relationship.

I really liked how the article broke down the cognitive functional training stages, but I have found in clinical practice that it’s not cut and dry. Each stage overlaps with each other with incorporating functional movements, managing fluctuations, and changing pain perceptions. It’s not so much a linear process, but a continuous cycle between introducing functional tasks and reflection on pain education and decreasing fear.

Could you send us the powerpoint slide that talked about your resident process? I though that was brilliant. As well, did you get a chance to watch the video in the O-Sullivan article in the cognitive training stage? I can’t seem to find it online.

[Laura Thornton]

1. I agree with you Sean. My first train of thought is to classify this patient in the clinical instability category. Key subjective/objective asterisks: previous lumbar fusion at L5-S1, no hypomobility noted within L4-5 or L3-4, just pain; aberrant flexion and return from flexion; pain with transitional movements, (+) prone ASLR. Tests you could perform to confirm/support this hypothesis: vertical compression test, H & I testing, and prone instability test.

I also think there is a maladaptive component with his case and seems like he has a one-dimensional view on his condition. These statements are pretty concerning to me:
• “Right side sciatic pain that has led to lower back, SIJ pain and stiffness
• “I can feel my disc rubbing on that nerve where I had my surgery, the way it did before”.
• “My lateral leg is numb, in the L5 dermatome.”

It sounds like he already has made conclusions about what is happening. He is an educated, medical professional who is probably not going to be swayed easily in changing his opinions. At least not right away. He also seems to me to be the perfect pain analogy of the “lion following you around”, where patients have this pain as the overarching, single, separate entity that has no relationship to how you move, it will just always be there until we have surgery to take it away.

I really attempt to dive into what was going on in the patient’s life around the time when the pain starts. Changes in exercise, changes in work environment, changes in home environment, changes in diet, changes in driving habits, all that could have had an effect on their movement patterns. Sitting for long periods of time could have certainly affected him, but what about his sitting posture and environment. Did he stay rotated towards one side versus the other? Is he a leg crosser? What about this has changed from the initial onset?

In my (short) experience, patients have appreciated taking part and collaborating with problem solving. Just as well, they appreciate us concentrating on their specific goals. What does he feel that he can get out of physical therapy? What brought him to seek out a physical therapist initially? What does he want to be able to get back to? Maybe not trying to change his beliefs right away, but working with him gradually to show how he can move OR changing one thing at a time about his movements in daily life. Once he can see the value that you can provide in a functional, movement sense, then start talking with him again about his beliefs as irritability and pain reduce.

[Laura Thornton]

For my article search, I decided to explore the current research on early passive range of motion for rotator cuff repairs. I just evaluated several this past week and each patient has slightly different surgical procedure as well as home environment/spousal support in terms of assisting with exercises at home.

PICO: In patients who have undergone rotator cuff repair within the past 7 days, what is the optimal frequency, duration, and type of passive manual therapy techniques for the first 6 weeks to maximize long term functional outcome?

I copy-and-pasted the search string and then under “name of disease”, I placed “rotator cuff repair.”

Narrow search strategy: 30
Expanded search strategy: 841

Right off the bat with the narrow search strategy, I found 5 appropriate articles on the first page looking at early rehabilitation protocols (slow vs. accelerated), including randomized controlled trials. The expanded search strategy included a lot more of surgical procedures and I needed to go through 3 pages to find as many appropriate articles. The narrow search strategy was already a headache saver from the start.

Most articles compare daily passive range of motion vs. delayed range of motion until 6 weeks. A meta-analysis of randomized controlled trials was published this past May in AJSM on early vs. delayed passive range of motion exercises. They found that there was no long-term difference in functional outcome with adding early range of motion in the first 6 weeks of rehabilitation, however short term improvements were made with flexion range of motion and therefore recovery of deficits from ROM limitations could be facilitated. The frequency of visits varied from 3-7 days a weekThere was an elevated rate of recurrent tears with massive to full tears with the early passive range of motion exercises. The authors conclude that early ROM exercises is preferable in cases without the risk of improper healing but with the risk of shoulders stiffness. Gradual and cautious passive range of motion is encouraged.

The narrow search strategy was extremely helpful in this case. Rotator cuff repair is a common procedure and well-researched, therefore a narrower search was optimal to save time and effort in finding appropriate articles. It was worth initially to search with the narrow string and based on how successful this strategy was, I wouldn’t have needed to do the broad string at all if I was limited on time.

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[Laura Thornton]

I like this article because it provides a well-detailed, comprehensive approach encompassing multi-modal interventions. The exercise/manual therapy and the motor control protocols were well thought out and very detailed. The article shows that normalizing movement patterns to optimize loading environment can provide successful outcomes in pain and function with subacromial syndromes (a sentence that I grabbed from the most recent issue of JOSPT on tendinopathy that I thought was very applicable).

I liked the strengthening progression that they used and that there was no time limit on how long that each patient stayed within each phase. However, I’m not sure if it’s feasible for all the patients to able to complete Phase 3 in 6 weeks. We don’t know where each patient stood at the end of the study, unless this was given and I missed it.

1. I agree, there is some misconnect between the commonly seen painful arc of motion in a higher range than where they measured ACH distance. In the Michener article they referenced for the sensitivity and specificity of the cluster, they state the painful arc is between 60 and 120 degrees going along with the Graichen articles and VOMPTI presentation.

Can anyone get access to the Desmeules et al. 2004 article on why they found that the most important narrowing is observed at 45 degrees?

Thanks for posting that video, good stuff!

[Laura Thornton]

Interesting point with the hip. I’d also be interested in looking more into her hip since she had an empty end feel and significant limitation in ROM. I probably wouldn’t rule this out yet. Was the pain she felt with hip flexion or extension HER pain? Doesn’t exactly explain the numbness, but might be a contributory factor. What’s her gait look like?

[Laura Thornton]

Are you thinking upper lumbar at all? The numbness in the lateral thigh, the stiffness in lower thoracic. Was her joint mobility normal and pain-free?

[Laura Thornton]

I was the same way with the statistics…I looked over this one for awhile.

Alex and Oksana I think you guys make good points about when a patient is highly irritable and a lot of the tests are positive, it’s hard to differentiate the structure at fault. The authors talk about one of the limitations of this study is that a lot of these patients probably are in the highly irritable side of the spectrum if they are appropriate for arthroscopic assessment and intervention so how clouded are our tests at this stage?

That’s a great example with the shoulder and treatment of 1. passive restraint vs. subacrominal disorder than 2. impingement vs. supraspinatus tendinopathy. It’s hard to tell how much our treatment approach would change for #2 if we could make a specific diagnosis like that.

I think with a lot of our PT interventions, we are affecting more structures around the shoulder joint than an arthroscopic intervention so the importance of specific pathology in specific structure might not be so crucial for our intervention. For example, with postural strengthening exercises to improve shoulder mechanics during elevation with subacrominal disorder, we are changing not only the muscle coordination/control and strength of contraction of the target muscles, but training the positioning of the shoulder and taking stress of painful subacromial structures (might not know the exact one). With an arthroscopic intervention, they are targeting one or two very specific pathologies of the shoulder and not much else.

[Laura Thornton]

Attached the article:

[Laura Thornton]

Really interesting article because I think it portrays a similar frustration that we face as providers of conservative treatment for this patient population.

The numbers of patients who declined participation in the trial based on the CHANCE of them receiving PT treatment as well as the number of cross-overs from PT to surgery and non-compliance with PT treatment shows the amount of obstacles we have to pass to show actual positive effects of conservative treatment only. In that sense, it is even more impressive that the results showed similar SF-32 outcomes, especially when you look at Appendix 2 with separating the crossovers from the patients who stayed with PT only.

Along with this, the intention to treat analysis is based on the number of patients who were offered initial PT treatment and includes the crossovers to the surgical group during the study. It’s somewhat difficult to take these results and conclude the similar effect of conservative treatment to surgical in all of the outcome measures. How are we to tell? Are the results from Appendix 2 a more important distinction then?

I’m having difficulty in understanding the importance of the CACE estimate. The difference in PT compliers vs. the number of patients in the surgical group who would have complied with PT if had been randomized to PT instead? Does anyone else think this is a bit hard to generalize?

[Laura Thornton]

Thanks for posting this article and about the patient case. I appreciate breaking down the intervention into distinct stages because there can be so much to cover with these patients and it’s a little daunting on how to approach this type of intervention. Can’t wait to learn even more.

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