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Adding to this a little late, sorry guys!
I like what everyone was saying about the dizziness but I would also want to make sure she’s cleared from a fracture standpoint. Given the mechanism, symptoms, and the emergency room x-ray (depending on the hospital), I don’t always trust the initial imaging findings. Depending on other risk factors she may have (ex: prolonged steroid use), I would be careful with my objective exam on day 1 and definitely perform both a subjective and objective screen for a cervical spine fracture prior to doing a lot of the dizziness testing – especially tests like Dix Hallpike that put the head into rather extreme positions.
Great topic, Kyle – question: what was she coming in for? I’m assuming post op ACL based on the article.
How do you address it, who do you include: I think this really depends on the therapist/patient relationship as well as the involvement of the parents. Some kids I’ve worked with are dropped off by the parent and I never see the adults unless I seek them out. In that scenario, I would start with just talking to the patient. Other times, the parent is over involved and stays for every PT session and is a helicopter parent. What I’ve learned about the patient/parent relationship would determine if I start by talking to just the patient or the parent as well. Middle school is such a tough time – it’s hard to know if the change in behavior is due to hormones or boy trouble or friend trouble or something more serious like a home life issue. Hopefully by this point you and the patient have bonded fairly well, so I usually take a rather direct approach and just bring it up. Like “hey Emily, where are those school colors today?” and just see what she says. I go that route for a while until I can get them to open up and talk with me about what’s going on. If I’m not getting anywhere, I may then opt for a sit down conversation with the patient and the parent in a more serious setting to discuss the drastic change in behavior. Side note – I would also try to be introspective and see if I had changed anything in PT to correlate with the behavior change. Like did I start spending less time with the patient or did I bring in a student to help? Likely not the true cause but things like that can matter a lot to patients sometimes.
I like that the article broke down 3 major themes that influence ACLR recovery and that the themes incorporated the biopsychosocial model. I think the big things for this patient would be confidence, accountability, and social support. She may have shifted away from sports focus because she is having confidence issues and is not sure she’ll be able to keep up with her teammates or be as good as she was prior to surgery. Again, hopefully that therapist/patient relationship is solid and you can bring this up. If it’s not, maybe that’s the issue.
How is this different from a 24 year old: Again, hormones! Being a kid can be rough and their perspective on life is obviously much different than a 24 year old. It can seem like the end of the world for a 12 year old who got in a fight with her best friend. I try to relate to kids and meet them on their level to justify their feelings and provide support. I would have a conversation with the 24 year old if the situation was the same, but it would look a little different. I’d still try to figure out what’s leading to the change in behavior but may start by just pointing it out to them and asking what happened.
Good thing I haven’t been eating cucumbers and cabbage recently… think this means I don’t have to wear a mask?! Just kidding of course.
My earliest memory of correlation vs causation is the example of ice cream consumption leading to murder because of the correlation between rate of murders and ice cream sales (since both are high in the summer). In glaring examples like this one it’s easy to clearly understand that correlation is not causation, however, things aren’t always that clear cut like in Anna’s ACL-R example.
It’s incredibly difficult if not impossible to control for every variable. While correlational studies are still important and add value, I tend to weight them lower on the totem pole of evidence than causation studies.
Diagnoses: primary – femoral stress fracture, differentials – hip flexor strain, pubic symphysis dysfunction, pelvic floor dysfunction, visceral referral (appendix, ovary)
Treat/refer: Refer and treat – may need an MRI, however, will a confirmatory diagnosis alter patient management? Unlikely to be displaced (probably not going in for surgery), so I would modify her activity and treat her like she has a stress fracture for a few weeks before really pushing for the MRI. I would also continue to treat with non weight bearing exercises to improve muscular strength of the hip girdle if indicated in assessment.
Continued treatment: pain free exercises for hip strengthening that are in a limited range of motion – progressive glute bridges, side planks. Discourage patient from running at this time. Lots of education, refer to RD for nutrition consult.
“It is imperative that clinicians consider the possibility of false-negative radiographic findings and treat suspected stress fractures as such until proven otherwise.”
The pictures in Eric’s article… super unfortunate injury. I would also question this patient on training during her adolescent years – as the article points out, if she had disordered eating and excessive running when she was younger, that could have set her up for low bone density currently.
1) Search terms – I think it depends on what your PICO question was but given the patient case, it seems like a good search strategy. How many articles did it yield? I feel like that’s usually a good indicator of strategy – if it’s a ton of articles OR just one it’s not great. Only thing I might have added or played around with would be “cervicalgia” or “cervical spine pain”
2a) SNAGs pre article: I like using SNAGs when indicated in the clinic. I think proper technique can be tricky for patients to learn, but clinically speaking they seem to be helpful. I haven’t read much research on them though.
2b) SNAGs post article: Despite some limitations, the study seems to positively influence my practice with support of SNAGs for Cervicogenic headaches.3) Findings/limitations: The authors conclusion of SNAGs being beneficial for treating cervicogenic headache seems to be supported by the data. I think it’s interesting patients were only taught the exercise once and then expected to do it (and do it correctly) daily for a year. I’m not sure you can convey value or ensure correct form from just one visit. They also did not account for the patients seeking other treatments (PT, medication, Chiro, etc) during the year. I’m also not entirely convinced that SNAGs on their own are all that fantastic – if you’re trying to restore ROM and improve joint mobility, don’t you need to follow that up with some neuromuscular re-ed? I’m skeptical of the big improvements they saw from just one exercise.
4) Cervicogenic dizziness: Yes – I tend to treat upper cervical dysfunctions manually (SOR, distraction, mobilization) and follow it with proprioception based exercises (using a laser with targets on the wall) and/or deep cervical flexor training if indicated.
Subjective – I think Anna and Taylor’s line of questioning is great. The only thing I would add is getting a better idea from her on big picture and daily timeline. Over the past 4 years has her pain been fluctuating? Is her pain different first thing in the morning compared to at the end of the day? Lastly, what has the dentist already done for her? It would be good to know if this is one of those situations where she’s been through 20 mouth guards with no relief.
Psychosocial – I definitely still struggle with this, but this patient is one that I would spend SO much time talking to and listening to. It sounds like she’s got a lot on her plate, and it may help her pain for the PT to just listen to her story and express empathy. I would also gently start to educate her on how pain works – my approach with someone like this would be to give her the basic science and then maybe use some examples involving kids. That way she hopefully feels less like we’re telling her it’s in her head or personally offending her. I think Anna’s point about asking her if she’s noticed a link between her jaw pain and stress is super valid. Sometimes just pointing that out is helpful. I also have no qualms about asking someone if they are seeing a mental health professional, so I’d ask her that. And then try to figure out some ways to incorporate things she likes doing/relaxation activities into her day.
Treatment – again, I agree with Anna and Taylor. I don’t really know if when the click happens matters a ton. I would for sure be looking at both sides to see if maybe a hypomobility on the “unaffected” side is contributing to issues on the affected side. I’d check her cervical spine out too since the two are usually linked and since she’s reporting headaches. It also seems like this is a patient who would do well with less frequent visits, and probably appreciate a solid HEP rather than having to come into the clinic. Depending on how the education is going, she may be one that I’d recommend Mosely’s book to. That way she can work through it on her on at home whenever she has time.
I actually think this is fantastic.
“Continually asking patients to rate their pain on a scale that is anchored by a pain-free state (i.e. 0) implies that being pain free is a readily attainable treatment goal, which may contribute to unrealistic expectations for complete relief.”
SUCH a good point. And while we as clinicians may be okay with a chronic pain patient getting down to a 3/10, they may be frustrated by not getting to a zero, vs if you reframe it to be a tolerability question, it’s a whole lot better for us to agree that “tolerable” is a win if it was previously “not tolerable.”
Another great point: the regular pain scale “reduces the experience of chronic pain to a single dimension” – so true and not a great way to try to capture the multi-faceted experience. I think a tolerability scale helps with communication too. As the authors pointed out, some patients that indicated a 6/10 pain then said it was tolerable, which may help us not move forward with higher risk treatment or referral when it’s not warranted.
1) No, I think it was perfectly acceptable and it gave you a good number of results which I think is always a good indicator. If it’s too broad, you’ll get a million results and if it’s too narrow you may only get a couple. I think your terms were specific to your PICO question and 14 results seems reasonable.
2) Strengths:
– Good to compare one manipulation to another (vs manipulation compared to inactive ultrasound) because it controls more variables, such as the general effect of being manipulation, therapist touching the patient, etc
– I like their outcome measures (pain, disability, ROM) because they seem to include all the important things – something subjective, something functional, and something objectiveWeaknesses:
– Done in Spain (do they practice the same as us?)
– It doesn’t sound like they did “both side” for the cervical manipulation group. Based on knowing that we usually do “both sides” for cervical manipulation since it’s not super specific and that they did that for the CTJ manipulation, that may be something they could have done differently.3) As always, it’s “the more you know”, right? I think this along with all the other articles about manipulation help me make a better clinical decision. As we discussed before, journal reputation, impact factor, etc all play a role. I think this is good information that may lead me to do multiple manipulations (as opposed to just one) on patients similar to those in this study, however I’d like to see some more research with a bigger sample size.
Similar to Anna, I have very little experience with treating hands and haven’t ever seen anyone post op.
I would likely refer her for a splint/brace but then I feel comfortable continuing with physical therapy. Like Anna and Taylor mentioned, education about activity modification and strategies for picking up her granddaughter would be very beneficial in addition to manual therapy and exercise. I don’t think she needs a referral for surgery at this point as it has only been going on for 3 months and is associated with increased activity. I anticipate her doing well with conservative management through PT and bracing.
Such a good case, Barrett! I’ve had one patient that was a “coper” (fully torn ACL per imaging, no surgery) and he did great. He was athletic pre and post injury and able to do all the things he wanted to do. I definitely think it’s worth calling him and the surgeon to discuss… I don’t have good research articles but read in a MedBridge post that ACLR patients are actually more likely to develop earlier onset OA than those that don’t have surgery.
I think based on your case, your idea to go with motor control exercises is great. It seems like his only “symptoms” are with really high level activities so doing similar things in PT to challenge his stability and proprioception would likely be the best route. I also think it sounds like you identified him correctly based on the attached article. How was his single leg stance? I also attached another article that talks about non-surgical treatment for NON copers so it seems like a call is definitely warranted.
Initially when I graduated I was all system 2 then as I got more comfortable I shifted to system 1, and now that I’m in residency I’m back in 2 most of the time. I think those “I got this,” “slam dunk” type of patients have us in system 1 but we need to be careful to know when to switch back system 2. I think I’m sometimes guilty of ignoring some of those “triggers” that should cause me to go back towards system 2, and then I try to stick it out in system 1 for too long.
I think our clinical reasoning helps us avoid biases as best as possible by ruling in instead of out, casting a wide net initially, and really thinking about our thinking while treating patients.
I’m so glad I watched this webinar! I was pretty unsure about BFR and didn’t know much about it so it was helpful to see more information about it.
My biggest thing is that I want to try it on myself before I put it on a patient or make any big moves towards implementing it. I think the potential is there for it to be pretty helpful, but I’d like to see it in action first.
I think it could be really good for post op patients that can’t load very much but need to get muscles working and gain strength. Thinking quads post knee surgery and gastroc post achilles repair…it could be just another tool in the toolbox. I tend to think we treat patients best when we have a bunch of options to work with. If our typical go-tos aren’t working, what else could we try? None of these “modalities” (dry needling, BFR, laser..) are end-all-be-alls or a magic cure, but if they can help get patients better faster, why not use them?
“Quadriceps strengthening with blood flow restriction for the rehabilitation of patients with knee conditions: A systematic review with meta-analysis”
I don’t have access to the full article, but the abstract of this article makes the point that in patients with knee conditions where we need to strengthen the quads, sometimes loading enough to create strength changes is too painful so BFR could be a good way to bridge between load and pain level.The attached article is from BJSM and is a meta-analysis which seems to point favorably towards the use of BFR..
First of all, this author is definitely on a soapbox…
Anna/Steve – totally agree, I usually do the tests but don’t put a whole ton of stake in them
Anna/Barrett – also agree to the point about identifying a specific structure at fault. In some body regions I think this is very appropriate but for the shoulder, with as interconnected as everything is, I’m not sure it’s appropriate to attempt to identify one specific structure at fault. I find myself spending SO MUCH TIME trying to identify a structure, that I often wonder if I had just started treating the impairments if they would be getting better faster…
All in all, I think special tests DO have a place in a shoulder evaluation. It’s a cluster just like everything else in PT is, and within the cluster there is a hierarchy of information. Special tests are lower on that totem pole for me than some other subjective/objective info as Taylor mentioned. I think I tend to use special test results broadly rather than using them to point to a specific tissue at fault. For example, I may think “this shoulder does not like compression” with the crank test or “this shoulder does not like internal rotation” with Hawkins Kennedy.
Lastly, to the author’s point about imaging: isn’t it true for most body regions that imaging findings don’t correlate to pain? I think this speaks to a more comprehensive approach to an evaluation, taking into consideration pain neuroscience and other psychosocial factors. Again, just more data points for the cluster…
I think one of the biggest take aways (that others are pointing out as well) is to know your source and do your part to determine if it/they are trustworthy, and using metrics is one way to do that. Just as we evaluate journal articles to see impact factor and how reliable they are, we should be doing the same thing on social media. As Taylor was saying, social media definitely points out trends whether good ones or bad ones.
I think that social media could have a positive impact on our profession as a whole, however, I don’t think it is the best place to look for research based guidance to your practice due to platform biases like Anna and Taylor mentioned. It is interesting though that the article says: “It is possible that promotion through multiple social media platforms expands the number of readers who are ultimately reached.” Maybe social media could be another way to get research pushed to you, like we’ve talked so much about in VOMPTI?
One of the biggest things that the field of PT needs to figure out is how to reach people – so many people STILL don’t know that we have direct access and they can come straight to us without a physician referral. To me, that’s unacceptable and points out that we as a profession are falling short and doing a disservice to the community. This is an area that social media COULD be helpful – I would argue that a large majority of the population is on social media in some form or fashion and if we can promote PT to them to educate them on what we do and why they need us, that would be a win in my book. The use of social media to educate the general population about PT could be a better route than PTs getting informed on research…
On a different note, I appreciate the ingenuity with exercises seen on social media. I’ll occasionally get ideas about a new thing to try or a new way to do an old exercise, and I think that helps spur my own personal creativity as well.
1) I basically do what you did, though I’m not super strong with searching research either. I try to get the list down to a manageable number (by PEDRO score, year, maybe journal, etc) then read through titles and abstracts.
2) While the exercises seem totally not functional, CSE more some than the PNF with the progression to chops, I think the frequency/time of visits (3 weekly 30 min sessions for 4 weeks) is at least similar to what we’d do in the clinic. I’m also SUPER confused by all the rest? They were having participants rest 30 seconds between REPS and then a full minute between sets, meaning they rested 5 1/2 minutes per exercise while only working for 50 seconds. Seems pretty underdosed to me.. And for the exercises that weren’t a hold they still rested between reps. I just can’t imagine dong ONE bridge then taking a 30 second break… I also agree with Anna that I think the control group did overall less exercise in general since it was only 20 min total compared to 30 min and they did fewer exercises.
3) Great points, Taylor – thanks for looking into that! Given that in functional activities we aren’t activating those muscles in isolation, it seems pretty clinically irrelevant to me to try to look at activation of the individual muscles (which are tiny…), not even considering it’s not a very reliable technique to begin with.
4) This is an age-old debate about the TA I think… I was under the impression it had kind of been settled that general exercise is just as good as TA specific exercise. I think we just need to load people and get them moving!