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1) labral tear (instability); RTC tendinopathy, bicep tendinopathy
2) GH and scapulothoracic joint mobility; Speeds Test
3) Likely shoulder instability, possibly due to labral pathology/tear.
4) If we’re thinking instability, I’d probably start with some proprioceptive exercises or provide perturbations in a pain free range (maybe supine at 90 degrees flexion) to start to work on stability.
Interesting article… As much as we as clinicians discuss the topic of within and between session changes it is interesting that the authors could only find 13 studies that met inclusion/exclusion criteria. Like most things with PT, I think this may a hard area to research appropriately which may have contributed to the lack of significant findings.
I think within/between session changes are good for rapport and open a door for education, but in terms of using those changes to determine prognosis, I think like everything else it should be a cluster. Those changes are just one of many variables we should be considering when determining prognosis. Many of those variables may go hand in hand, like the presence of yellow flags that would lead to a poorer prognosis may also cause difficulty in making within session changes.
This was (maybe unfortunately for us) a very well done article based on the PEDro scale.
Everyone has made really good points so far. It’s hard to think that our go-to interventions may not actually be making much of a difference for these patients.
As Taylor mentioned, I think the authorized did not emphasize the effect of PT interaction/belief in interventions enough. It would be interesting to know how much of an effect there was just by going to the appointments and interacting with a caring therapist. They almost need a 3rd group that did literally nothing, or just something at home.
As Taylor, Anna, and Lauren were commenting on: I wondering how much effect the severity of the arthritis has on the treatment. I think we discussed last weekend that we are most effective with low to moderate arthritis so maybe the impairments in the included group were more severe than that? Also, I agree with Lauren that the exclusion criteria were quite limiting (no exercise more than 1x/week, limited walking) so it’d be interesting to see the same study done in a more active group.
I’ll continue to treat these individuals with manual therapy and exercise, but also put more on an emphasis on education and activity modifications (assistive device) when indicated. As Eric as mentioned before – just because it’s not supported in the literature doesn’t mean we should completely change our practice pattern. Just good to know what the research is saying on things we assume.
1) Hypotheses after subjective: lumbar radiculopathy (primary, L3/4), facet referral, hip pathology, disc (L3/4) referral
2) Pattern – yes, still seems to be L3/4 radiculopathy, however, it is interesting that SLR was negative
3) Possibly slump (or prone Ely’s?), quadrant testing, repeated motions (does repeated extension diminish the tingling?)
4) Given there are no significant red flags, I would feel comfortable treating him. I would address the lack of hip extension, possible nerve glide, address quad weakness (mini squat). I’d be curious to know more about what makes his symptoms peripheralize/centralize – were you able to bring them on or get them to go away with anything you did? He seems to be fitting into the “specific exercise” category (pending thoughts on centralizing/peripheralizing).
Alright so… thanks for challenging my practice, Eric :) Several things have happened in the past week. I’ve spent a ridiculous amount of time trying to find the articles I thought I was remembering and asking a bunch of people to assist in the search but.. there’s not much on it. What I was remembering was a student presentation on manual lymph drainage, and my mentor saying she uses it and thought there was research to support it. What I meant by “techniques” is the “pet the cat” method of gently stroking the skin (distal to proximal) to encourage lymphatic circulation and blood flow. Most research I found was on it being helpful for breast cancer/managing lymphedema but not on general post op for other things. Also, most of the articles that I found that were supporting it, supported it more based on reduced pain and improved knee ROM rather than decreased swelling. I attached a systematic review that basically says we need more research. In conclusion, I still don’t really know what the answer is but I’m thinking this technique is no longer going to be one I implement…
This is so cool!! I love what he said – “sometimes you need to believe it to see it.” This is totally applicable to what we do. Sometimes, we just need to believe that we are doing the technique correctly and believe that what we are trying to do is actually happening. I also think it’s interesting that you have to first commit to a prediction in order to learn something. This makes the process way more active – the metacognition, or thinking about your thinking, needs to be an active process to get something out of it.
The second video – this is clinical reasoning at it’s finest, right? We start to look at things with patients (how they present, what they say) and start to form predictions about what we will find (limited range of motion, hyporeflexia) and then we check our predictions as we continue examining. As we get better at it, our predictions are more likely to be accurate and we start to pick up on patterns and learn on our past knowledge about the presentations more.
Information overload for sure but good for you for doing all this research! I couldn’t access the first article or the “rehab principles – 12 steps for success” article just fyi.
1) What objective measures do you use throughout to track progress?
Obviously range of motion, pain scale, and girth… I try to also use quad strength but without actually testing it early on – i.e. knee extension lag for SLR2) What are your go-to techniques to gain terminal knee extension and get the patient to utilize it during exercise and gait?
All closed chain stuff – mini squats, TKE with band, step ups, light leg press3) What does your HEP look like early on and as rehab progresses?
Depends on the MD protocol and my conversation with the doctor. Per Eric’s question, I base those decisions on the op report (complications, repairs other than just the ACL, graft site/type, etc), the patient presentation (high pain levels, psychosocial factors), and obviously objective measures and my clinical reasoning based on how I’m seeing them move in the clinic. I think quad sets and SLR are great but if they’re able to weight bear I prefer more functional closed chain exercises. I also try to integrate things that are specific to their goals – do they play a sport, lift, run, etc – helps with keeping their spirits up and prepares them early for return to sport. I also try to keep the whole kinetic chain in mind. Just like we were talking about with do a forward reach with a row for the shoulder instead of just an isolated row, I try to do that for the knee too. If we can keep their trunk engaged and make activities functional, even though they’re lower intensity for the actual knee, I think it helps return to sport faster.4) How often are you seeing these patients early on and as they progress through each stage of rehab?
Depends on the patient! Those that I feel are pretty self sufficient, I don’t feel the need to have them come in and more basic exercises if they can do them at home. Depends on if I feel that I can add something new each time I see them (provide a different type of stimulus).5) Thoughts on open chain kinetic exercises?
Meh… I don’t place a ton of value in them because they’re not very functional.Final thought: I teach everyone lymphatic drainage techniques post op! There’s some good research on it actually making a difference.
1) Is there any more information you would have gathered during the subjective? Are there any other outcome measures you would have administered?
– I tend to do QuickDASH for elbow and hand and SPADI for shoulder, so I probably would do SPADI though I don’t think you’re wrong! Maybe NDI as well to capture neck contribution.
– I might want to know more details about the MVA/imaging – how fast was the other car and her car going? Did she have anyone with her? Did she go to the hospital from the wreck or was the imaging later? How did she feel that day and the next day compared to now?
– How long has she been on light duty/what does that entail compared to her normal responsibilities?
– Is she normally a R side sleeper/is her sleep disturbed?
– How much/how often for the meds (NSAIDs and muscle relaxer) – wondering if we are getting a true/clear picture of her symptoms/irritability based on when she last took something, and curious about how much work it will take to get her off of them2) Based on body diagram and subjective exam is there anything else on your differential list? Is there anything you would change on mine?
– I still have upper cervical instability on my list (did the imaging just rule out fracture/what about ligamentous laxity?)
– I think I’d have the cervical stuff higher on my list until proven otherwise. I feel like neck movement affecting shoulder symptoms tends to be more neck pathology vs a true shoulder pathology may be less affected by neck movement3) Considering irritability would you have changed your objective exam? What would you have done differently?
– I think it depends on why you have mod/severe for irritability – once her symptoms come on, how long does it take for them to subside? We know arm movement brings on all the symptoms, but do they go away pretty quickly once she returns to resting position?
– I think your exam was great! I’m curious if her cervical symptoms with AROM would change if you unweighted the shoulder girdle by putting her hand on her opposite shoulder.
– Cervical radiculopathy cluster?4) What is/are your primary hypothesis or hypotheses?
– WAD, C5/6 radic5) What would your PICO question be for this patient?
– In patients with WAD, is manual therapy or manual therapy with exercise more effective for restoring cervical range of motion?Working hypothesis and differential diagnosis:
a.) What is your working hypothesis regarding this patient? GH instability/labrum pathology
b.) What are your next 2-3 differentials? (Ranking order) thoracic outlet, cervical radiculopathy, RTC tendinopathySpecial testing:
a.) What are your thoughts regarding the special testing chosen for this patient? I think it was good, I might have included load and shift and crank to further assess instability symptoms.
b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why? See above, also maybe Jobe to look at RTC involvement.Clinical Pattern:
a.) Does this patient’s presentation fit a clinical pattern? Not a true pattern – seems “nerve-y” possibility from shoulder or neck.
b.) Briefly, what are your thoughts regarding his headache? I think it’s worth asking him if it seems related to his shoulder pain at all. He might not have indicated it on the body chart because the patient doesn’t believe it’s related, up to us to determine if that’s actually the case.Evolution of Patient’s Symptoms:
a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI. – I feel like this is more common than we actually think. Symptoms tend to be “bucket effect” where it’s a lot of things that contribute to the manifestation of symptoms and then a “final straw.”
b.) Are there any red flags? I don’t think so.Treatment
What Manual therapy and HEP would you give the patient on the first day? manual facilitation of scapular upward rotation with MWM technique in scaption; did you look at scapular motions in sidelying? seems like a scap mob could be worthwhile depending on what that revealed; prone ITY for HEPI like the idea of using this questionnaire to start the conversation about pain. I often find it challenging to figure out how to bring up pain science stuff, or where best to insert it in conversation. If patients filled this out in their eval paperwork, we could open the door day 1 to talk through it which would in turn lead to pain science talks. I also like that we could use the questionnaire to see how effective we are with our education – hopefully the score improves as we talk through pain science things with the patient.
I have SUCH a hard time trying to change the way patients think about pain. I feel like people usually get defensive or think what I’m talking about doesn’t apply to them. The “Assessing beliefs..” article makes an interesting point – it is harder to elicit positive metacognitions, therefore, we should target negative metacognitions first to help the patient develop meta-cognitive awareness in order to then be open to positive beliefs about worry/rumination. Gives us a good starting point on what order of operations to address metacognitions. I think a big challenge is when people think they are doing the right thing by worrying or analyzing their pain (thinking it is helpful to get out of pain and will avoid future “damage”) and then we try to tell them to do less of that… It’s hard to think that we don’t make them more worried by telling them not to worry – it’s like “think about anything except the elephant in the room” and all you can do is think about the one thing you aren’t supposed to be thinking about. I think the part of the “metacognition, perseverative thinking..” article that says “equipping people with chronic pain skills to attenuate perseverative thinking might be one way to reduce their pain catastrophizing” and “explicitly addressing unhelpful metacognitions through Socratic dialogue and behavioral experiments” is really great, except I’m not quite sure what that looks like in practice.
Yes, Steve! I was really impressed by the resident’s clinical reasoning skills and how they walked through the process in the article. I still feel like I really struggle with having a flow for my thought process and examination…
I thought this article was a good example of the use of clustering signs/symptoms from subjective and objective to make a diagnosis in the case where special tests aren’t great. I also thought it was a good example of diagnosing by ruling everything else out, instead of trying to rule in the suspected diagnosis. And as Lauren and Anna mentioned, a great review of the anatomy of the forearm and possible nerve entrapment sites – something that I definitely could stand to review. In terms of treatment, I tend to want to address all the deficits I see rather than hone in on the real issue first then incorporate everything else later. The author first focused on soft tissue to address the main cause of the symptoms, then gradually incorporated strengthening the surrounding areas.
Here are 2 articles about dry needling for TMD. Sounds like you’re on the right track with this patient!
So I’ll give you my 2 cents but like Taylor I haven’t done a whole ton of TMD stuff…
Cervical spine: The research points out that the cervical spine is almost always involved. I saw that you cleared the cervical spine but then gave her c-spine exercises anyway. I would maybe take a closer look at her cervical spine (especially upper given the headaches – does she feel those are associated her jaw pain?). That way maybe your treatment/exercises can be more specific to your findings, even if a general APR didn’t reveal much.
Activity modification – did you guys talk about foods to limit/limiting chewing gum?
What do you think about the Rocabado exercises and the Kraus TMJ exercises? And what about the multimodal approaches discussed in the second article? Maybe incorporating some ideas from those could be good for home exercises.
Which classification system would you put her in? I think myogenic and disk displacement with reduction. Did you look at the joint compression test?
What did you think her severity/irritability level was? Seems like determining irritability is especially important with TMD due to it’s influence on how you dose exercise (avoid under or over dosing).
Shout out to dry needling! I’ve had some good success with needing TMJ so it might be something on the books if you end up needing a leg up in the right direction. I’d at least incorporate a fair bit of soft tissue work with the masseter and temporalis.
1. Conclusions make sense?
Short answer: yes, I think so. However, the mean differences compared to the MCID and MDC was very close. For example the neck flexor endurance MDC is 17.8 seconds and the mean difference was only 18.45. So I think they showed that yes, manual therapy mobilization improves outcomes but I’m not sure by how much. Kevin talked about confidence intervals overlapping discrediting the findings and I’m not positive it’s the same thing, but the means in the table also overlap if you take standard deviation into account, which may negate the findings in this study. The other issue is that the only follow up was at 4 weeks, so the study doesn’t look at longer term outcomes.2. Relevance to clinical practice?
Able to use NDI, goniometer, neck muscle endurance test. We don’t use infrared lamps, ultrasound, and TENS. We are varying exercises and interventions throughout care as opposed to doing the exact same treatment each session. We do usually treat with CPAs and UPAs in manual therapy but also incorporate other techniques that were not studied.3. Limitations?
Eliminated patients with neurologic findings and discogenic disorders as well as history of cervical spine injury (but isn’t that most people who seek PT for their necks?). Blinding by telling the accessor and patients not to talk about treatment (truly blind?). Done in Pakistan – different than US? Routine physiotherapy – same exercises every time (not progressed), use of infrared lamp/ultrasound/TENS – not supported by literature. Cervical mobilization – different for each patient (patients do not all present the same way, different anatomy, etc). Inflexibility of routine physiotherapy, manual intervention based on symptoms. Patients using pain medication – same number in each group but same amount/type of medication? Compliance with HEP? Longer term outcomes? Residual confounding – unknown if standard number of sessions per week.4. How long?
I spent about an hour and a half reading through the article and thinking about the presented questions. We definitely don’t have time to do that while in the clinic! I find it difficult to translate research into clinical practice because to be a “good” research study it has to be so specific in terms of who the participants are and what the interventions are, which makes it less likely to be reflective of my actual patient or how I provide treatment. For example, can we use the findings in this article with patients who do have neurologic or discogenic problems? Also, what about manual therapy vs “routine PT” where routine PT is more specific to the patient and uses evidence based interventions rather than ultrasound and infrared lamps?