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Due to high irritability, I would place a lot of emphasis on patient education, including self-management strategies such as resting when tired and getting an appropriate amount of sleep, initial avoidance of aggravating environments such as loud noise or bright lights, gradual and progressive re-introduction of activity and those aggravating environments as symptoms improve, and stress management (music, meditation, aerobic exercise) as tolerated. I would also educate the patient on the prognosis behind their presentation and that many patients recover quickly after a concussion.
If I notice that symptoms are not improving or potentially getting more severe and I am unable to address any of the cervicothoracic or vestibular/ocular impairments, then I would refer the patient to a concussion specialist.
Given history of trauma and present signs/symptoms, I would prioritize red flag screening to rule out presence of CAD, upper cervical ligamentous instability, or myelopathy.
If red flags are clear, I would sequence my objective examination based on the level of irritability I determine in the subjective, initially starting with a screen of potential cervical/thoracic MSK impairment before assessing vestibular/oculomotor dysfunction due to the concern for a concussion.
If red flags aren’t clear, referral would be needed back to the ER due to the potential that their presentation could be potentially life altering if untreated immediately.
I agree with what both Clare and Emily stated in regards to further subjective questioning and objective procedures. Given the objective neuro findings and onset of new symptoms at this visit, my level of concern would be high due to the potential that this presentation, if not immediately treated, could cause long-term, life altering changes.
Therefore, I would hold therapy for that day and immediately refer the patient to the ER.
I agree with Emily that if the concern was for CES, I would anticipate more LMN s/s, but given the (+) Hoffman’s, my concern is higher for a space occupying lesion or spinal cord compression higher than the level of L1, which further emphasizes the need for an immediate emergency referral.
The first thought that comes to my mind with this case and this particular population is the strong influence that societal and environmental factors can have on their health condition, emotions, and motivation.
I feel my first plan of action in this case would be to simply talk with the patient about what I’m seeing. Hopefully at this point, I have established a good rapport with her and she feels comfortable sharing what she’s feeling and why she is losing motivation. I also feel it would be important to involve the patient’s parents and even coach(es) to discuss the sudden change in her participation and overall motivation with rehabilitation in order to establish an open line of communication and determine if they are seeing the same changes.
I know from my own personal experience with sports in high school, there’s a lot of overwhelming pressure to perform well and I can only imagine how much more pressure and anxiety I would’ve felt if returning to sport after a significant injury.
I would initially refer this patient to their referring provider as well as the PCP if this wasn’t who referred them to PT, since they are the one who recently changed the cholesterol medication. When communicating to referring providers, I try to utilize the SBAR method for effective communication and description of what I’m observing in the patient and why I feel a referral is warranted.
For this patient scenario, I would describe in detail what I’m observing in the patient both subjectively and objectively, how these findings differ from the examination, and what the timeline of change or trend in symptom changes has been. I would also try to make the connection between the change in medication and abnormal findings without outright blaming anyone for the patient’s abrupt change in symptoms out of respect for the other provider and in order to maintain an open line of communication.
I’m lucky with the system we use at UVA because the patient’s medications are often very easy to access, unless they are direct access or not in the Epic system. I typically try to review their chart pre-subjective exam for any significant medications or co-morbidities that could influence their presentation. I will be honest in saying that my knowledge on pharmacological treatments could be better, especially as it relates to side effects that could be induced from exercise.
A recent patient I evaluated came in with a separate diagnosis of myotonic dystrophy, a pathology I was completely unfamiliar with. After receiving advice from a mentor, I reached out to their neurologist about potential precautions or contraindications as it relates to exercise therapy. The neurologist sent me back a great resource that described in detail the PT management of this condition, as well as pertinent background info to help guide my treatment. If I hadn’t reached out, I feel my exercise prescription could’ve been too overwhelming for this patient and may have exacerbated her symptoms. I attached the resource in case anyone is interested!
In addition to the functional tests and 6MWT described by Clare and Emily, I would also use the bike test to help differentiate between stenosis and intermittent claudication based on this patient’s symptoms and PMHx. Biking may induce leg symptoms with the presence of vascular pathology due to the more forward flexion posturing.
Something I have been trying to utilize more in my own clinical practice is hand held dynamometer assessment. I definitely think this would be an important examination procedure for this patient in the event that they are experiencing statin-induced myopathy due to the change in medication. I feel MMT can still be a good tool to use for provocation during the examination, but I don’t think it gives appropriate objective information to determine baseline strength measurements, since it’s really just based on the clinician’s perception.
HHD testing would certainly show widespread weakness that could be occurring due to a change in this patient’s cholesterol medication after 6 PT visits, in addition to abnormal length of muscle soreness and changes in ADL performance.
1. Anterior disc displacement with reduction: chronic jaw symptoms with intermittent clicking, age, gender, PMHx of depression/anxiety, high stress.
-Are your symptoms unilateral or bilateral?
-When do you notice the clicking in your jaw? What activities/movements are associated with it?
-Do you ever have difficulty opening/closing your mouth or feel like somethings blocking you?
-Any change in your dental history over the last 4 years? (e.g. invisalign, night guard, surgeries, braces/retainers, etc.)
-Do you notice a relationship between high stress and increased jaw symptoms?2. Temporomandibular myofascial pain syndrome: chronic headaches/jaw symptoms, high stress life, PMHx anxiety/depression.
-Do you have a history of teeth grinding, clenching (bruxism)?
-Do you have pain with eating, especially hard foods?
-Do you have tenderness and pain on the side of your head, jaw, cheek?
-Do you feel there is a relationship between high levels of stress and increased jaw pain/headaches?3. Cervicogenic HA: chronic headaches, high stress.
-Is your headache and jaw pain aggravated with neck movements?
-Do you have increased headaches/jaw pain with prolonged static positioning?
-Does your pain start in your head and radiate to your jaw? Which comes first?4. Upper Cervical Ligamentous Disruption: chronic head/jaw pain, clicking
-History of MVA or neck trauma?
-Head/jaw pain with neck movements?
-PMH of RA? Bilateral joint pain/stiffness? Stiffness in AM >30 min?
-Feels like you have a lump in your throat? Feel like you have to constantly swallow?
-Numbness/tingling, pins/needles in head, jaw, neck, or UEs?5. Cervical Arterial Dissection: HA, jaw symptoms
-5 D’s And 3 N’s
-Location/description of HA – aura migraine, tension, cluster differential?
-Are your recent headaches familiar or unlike any other you’ve had?
-History of trauma?
-PMHx of HTN, DM, HLD, CT disorder?
-Are you a smoker?Given this patient’s presentation, history, and lack of previous conservative treatment, I would definitely choose the route of PT in isolation prior to any orthopedic referral. I found those articles to be really interesting but also humbling in the sense that I realize I didn’t know much of anything as it relates to treatment at the wrist/hand. They highlight the potential benefits of choosing conservative treatment for CMC OA, especially if initiated early on after the patient’s onset of symptoms.
Considerations that would lead me to PT in isolation over an orthopedic referral for 1st CMC OA include the severity of functional loss, level of pain, ROM loss, and the patient’s preferences/beliefs. In this case, I feel the patient is not at a severe enough point to need a referral and could be managed appropriately with PT, especially to reduce the overload her extrinsic EPL is likely getting due to poor intrinsic stability.
One resource I wanted to re-share that was actually shown to us in the knee OMPTS is the American College of Rheumatology Guideline for OA management in the hand, hip, and knee. I thought this was also helpful for understanding what the research supports for managing hand OA.
Objective exam components in ranking order:
Observation: swelling, discoloration, displacement/deformity (Keinbock’s and distal ulna fracture)
Active, passive ROM and resisted testing: TFCC – snapping/clicking with A/PROM and a springy end feel, pain greatest with pronation/supination; DRUJ instability – AROM loss and pain with pronation/supination and notable ulna dorsal displacement during pronation; ECU subluxation – pain with active wrist extension and supination (may produce a snap), resisted wrist extension, ulnar deviation; Distal ulnar fracture – capsular pattern of significant flexion = extension ROM loss compared to uninvolved side, pain & weakness with all active movements and resisted testing; Keinbock’s disease – decreased ROM into flexion/extension, capsular pattern with PROM.
Grip strength testing: Keinbock’s disease – significant grip strength loss compared to uninvolved side.
Special tests: TFCC – (+) TFCC compression/grind test (pain + click/crepitation), press test; DRUJ instability – (+) piano key sign, DRUJ ballottement test, dorsal RU shift test
Palpation: TFCC palpation, ECU tendon palpation over the ulnar head, dorsal RU ligament palpation with wrist in flexion, ulnar styloid (fracture), dorsal lunate (Keinbock’s)
With all these components, I feel the important points to consider when determining if a referral for imaging is warranted are a combination of decreased willingness to move, passive ROM empty or hard end feel, presence of ROM loss with a capsular pattern when compared to the uninvolved limb, observation of edema/discoloration, and grip weakness. These findings would certainly raise my suspicion that the patient has a pathology that would need to be managed differently than what PT can immediately provide.
Of the articles listed, I chose to read the Cowell et al. (2018) article, which used qualitative interviews with physiotherapists to help determine their perceptions towards managing chronic non-specific low back pain (CNSLBP). I thought the authors did a great job at finding so many common themes between physiotherapists on their perceptions, and those of which definitely ring true for me when I think of my own management of patients with CNSLBP. Specifically, I definitely agree that it can be a huge challenge to address the psychological factors that are contributing to this patient population’s pain, especially if there isn’t any current interprofessional management occurring. Reflecting on my own practice, I feel that something I have a bad tendency of doing is quickly moving on when a patient tells me that they are seeing a psychiatrist or psychologist for their mental health. From a BPS model perspective, I should be asking the patient about their experience with that provider, or even better, reaching out to that provider to help determine ways that I can help address coping or management strategies through treatment, if the patient is okay with that. I feel this would also help me gain the trust of my patient and they would be able to see how much I truly care, that I’m willing to take the time to reach out to another one of their providers to improve the quality of their care.
Another theme from the Cowell et al. article that rang true for me is avoiding reliance on passive treatment. We know from other literature we’ve discussed that manual therapy can most definitely play a role in pain modulation for the CNSLBP population. Similar to the physiotherapists interviewed in that article, I often find myself using manual therapy as a way to “break the ice” and provide an avenue for increased rapport. I use manual therapy as an opportunity to simultaneously perform pain neuroscience education or discuss the biopsychosocial impact on LBP as this is usually a time when both the patient and I are comfortable enough to discuss it. However, I think I could do a better job of setting expectations early and specifically making it clear that the progression of the treatment provided will move from hands on to functional independence exercise prescription. Similarly, I appreciate the discussion on promoting self-management with this patient population. This is certainly a challenging component for me, that is, communicating with this patient population in a way that promotes the comprehension and actual implementation of self management when they have been dealing with pain for more than a decade.
Just in this short time I’ve been a practicing clinician, I’ve seen a common theme that with those patients whom I am able to carefully and gradually introduce snippets of PNE or BPS management while simultaneously building a rapport via humor, a general interest in their life, or something we have in common, they often are far more accepting of the notion that they need to put in the work outside of PT in order to improve their pain long term. In other situations where I haven’t been as successful, patients stop coming to clinic or they simply brush me off by agreeing and moving on to another conversation topic. I think it’s clear that this patient population requires patience, compassion, and a mutual understanding of expectations in order to truly make an impact on their pain and disability. I plan to address my weaknesses by incorporating more motivational interviewing skills, searching for any sort of common ground with my patients to build upon the therapeutic relationship, and advocating for these patients in every way possible, including through the communication with their other healthcare providers with the patient’s approval/consent. I would love to hear anyone’s experience with addressing psychological factors with this patient population or working with mental health professionals to utilize coping strategies during PT treatment.
Resource:
Cowell I, O’Sullivan P, O’Sullivan K, Poyton R, McGregor A, Murtagh G. Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study. Muscul Sci and Pract. 2018;38:113-119. doi:10.1016/j.msksp.2018.10.006Triangular fibrocartilage complex (TFCC) articular disc tear – location of sx’s, recurrent swelling, traumatic compression injury to medial wrist, aggravated with weightbearing or upon impact in wrist extension (compressive). Does the patient endorse mechanical symptoms such as clicking when moving his wrist?
Chronic distal radioulnar joint (DRUJ) instability – length of time since injury, location of symptoms, aggravated with holding objects or upon impact with golf swing. Has the patient experienced grip weakness since the onset of this injury? Does he feel that he has lost an ability to turn/rotate his wrist? Does his wrist feel unstable?
Extensor Carpi Ulnaris (ECU) subluxation – dorsal directed force with wrist extension MOI, recurrent swelling that has improved with time, pain with active wrist extension and compression in wrist extension while weight bearing or playing golf. Does the patient report a painful snap at his wrist whenever he is turning his palm towards the ceiling? If so, does this improve when turning his palm back towards the floor?
Distal ulnar fracture- length of symptoms, recurrent swelling, traumatic MOI without full resolution of symptoms, pain with any impact, weight bearing, or load through the medial wrist. Did the patient hear a “crack” when the original incident occurred? Does the patient have a history of fractures or bony pathology? Was there any bruising after the initial injury?
Keinbock’s disease – demographics (young, male), traumatic MOI with ongoing chronic symptoms, recurrent swelling, intermittent pain with weightbearing or force through the wrist (golf swing). Has the patient noticed any loss of wrist range of motion since the incident? Has the patient ever injured his wrist in the past?
1) I feel that eccentrics should most certainly be a component of exercise prescription for patients presenting with tendinopathy, but they shouldn’t be the ONLY component. A somewhat recent article from 2019 by Cardoso et al. does a great job of summarizing the current trends in tendinopathy management with a breakdown of exercise prescription and what the research supports. They discuss the most updated research demonstrating the effectiveness of heavy slow resisted exercise for both Achilles and Patella tendinopathy management as well as the lack of evidence demonstrating eccentrics as an effective standalone treatment. With all that being said, I would incorporate eccentrics, along with concentrics, when I feel the patient has their pain at a manageable level. I certainly wouldn’t incorporate progressive isotonics for a patient presenting with an acute reactive tendinopathy, as this would likely increase or aggravate their symptoms. Progressive isotonics would be much more effective for a patient who can tolerate that load in order to reap the benefits, which includes the stimulation of increased tendon stiffness and strength. In the examination, I would expect those patients to present with a longer history of pain with some sort of chronic attenuation based on sport/hobby/vocation or episodic history, a low to moderate level of pain, observable thickening of the tendon, and perhaps some biomechanical deficits that contributed to torsion or compression to the tendon (e.g. muscle imbalances, ROM loss/excess, lack of adjacent area stability).
2) Pulling from a clinical experience as a student where I saw a patient with insertional tendinopathy who couldn’t tolerate eccentrics in weight bearing despite no movement below plantigrade, one initial modification I would try to make is to reduce the amount of load being placed on the tendon. This includes reducing body weight by using a machine such as a total gym/leg press or trying the exercise in a seated position. Another modification I have used when a patient with tendinopathy can’t tolerate eccentrics is having the patient perform only the concentric phase in single leg on the affected side, then lowering down with both legs eccentrically. The above idea of reduced body weight/load could also be applied in this scenario if weight bearing is too intolerable.
3) I definitely find that it can be difficult to explain exercise physiology to patients in general, especially when they are extra curious on how it works and I need to find a way to explain it in a way that makes sense to them. Usually how I try to describe eccentrics to patients goes something like this: “a majority of the exercise we perform involves two phases, the concentric and eccentric. In the concentric phase, the muscle/tendon we are targeting is shortening while contracting and in the eccentric phase, that same muscle/tendon complex is lengthening while contracting (this is usually where I would demonstrate as well). Both phases are needed for adequate muscle function and you can see that in a lot of daily activities, such as climbing stairs or squatting. Naturally, our muscles can produce more force during an eccentric movement than a concentric. The reason eccentric exercises can be highly effective for improving the strength of your tendon is that they cause more microtears due to the muscle having to produce more force in a lengthened position. These microtears are actually beneficial for our bodies, as they stimulate our natural healing response, which then allows the tendon to heal stronger with a better ability to handle and adapt to increased load.” Now, if the patient was an engineer, I would probably need to go in more depth and pull up a picture of the force-velocity curve. If anyone has any suggestions for how I could phrase that to make more sense, I would definitely appreciate it as I feel like it could probably be explained more simply or in a way that also emphasizes the importance of concentric movements.
References:
Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Prac Res Clin Rheum. 2019;33(1):122-140. doi:10.1016/j.berh.2019.02.001Current concepts review: Management of Achilles tendinopathy overview. J Arthro and Join Surg. 2021;8(3):216-221. doi:10.1016/j.jajs.2021.03.002
Something that has come up in mentoring sessions is the activation of the RTC muscles with various exercises, especially AAROM exercises that have more activation in EMG studies than one might think. Without going too off topic, I was wondering what everyone’s early intervention exercise prescription includes for patient’s that are post-op shoulder, especially when the procedure involved RTC repair. When should AAROM exercises be implemented to avoid over activation of the RTC and potential failure? Also, what do you think should be the guideline or threshold for RTC activation, how much is too much early on in rehab?
This article highlights the lack of reliability between post-op protocols that I feel is common in many of the orthopaedic post-op conditions we see in OP orthopaedics. As a new clinician, I’ve found myself using protocols often but as I’ve gotten more comfortable, they are becoming more of a guideline than step by step process as every patient progresses and presents differently. I think this article also speaks to the importance of using our clinical reasoning and knowledge on tissue healing timelines as well as exercise training principles to treat post-op patients.
Despite knowing the high prevalence of LBP, I found it surprising to hear the statistic from the O’Keefe et al. article that as of 2019, the US spends more money on spinal fusion surgery each year than any other surgery. When reading through both of the articles listed, I found myself thinking back and reflecting on the many patients I’ve evaluated and/or treated who present with low back pain. I can even think of a few patients I’ve seen who’ve had spinal fusion surgery, only to have their symptoms return shortly after rehab, or get worse. I know this isn’t the case with every patient who receives some form of spinal fusion surgery, but I think it highlights the lack of appropriate clinical decision making that is present when determining management strategies for patients with LBP.
I can admit I’ve found myself using language such as degeneration with patients and realizing in subsequent visits how much they held onto that word and the impact it made on the perception they have on their condition. I definitely realize the impact labels can have on how a patient feels towards their condition and how this can often lead to them taking unnecessary steps towards improving their symptoms, such as imaging and surgery. At UVA, we are often seeing patients via referral who have already had imaging done so more often than not, I find myself trying to educate patients more on what their imaging findings really mean rather than describing the purpose and use of imaging. I have to admit that sometimes explaining to patients the prevalence of various imaging findings in asymptomatic populations doesn’t always work, especially in the older population who place a lot more salience in the words of an older, experienced surgeon. The reality is that many healthcare providers aren’t taking the time to explain the imaging to their patients and aren’t giving them reassurance for the prevalence of the image findings and what conservative management options can do for them. Or perhaps it is an instance where the healthcare provider is relying on a biomedical approach to explain to their patients what is contributing to their pain. I really liked the reassurance line used in the O’Keefe et al. article for patients presenting with NSLBP: “I’m not worried that there is anything serious going on here. I think overall your outlook is good. Movement will help. The sooner we can get you back to your normal activity and work, the more likely your back pain is to get better.” Although there can definitely be more added to a statement like that and more patient education provided, I think it’s a nice statement to give the patient confidence that their presentation is not something to feel worried about and may even improve their trust in you as they see your own level of confidence.
The article by Lim et al. discusses the strong desire that patients with LBP express to have a ‘definitive diagnosis’ and explanation for their pain, which they often feel requires imaging. As I mentioned before, I am often not seeing patients who haven’t already been told what is likely contributing to their LBP based on imaging, or some other form of a biomedical approach. I do find that these patients who have a ‘definitive diagnosis’ to be challenging as they have started to develop firmly held beliefs that can be hard to break (cue AJ’s sandstone analogy). I certainly think I could improve my management of these patients by shifting their focus away from the label they’ve been given, and more towards what PT can do for them. In the LBP communication quiz, one video shows Peter O’Sullivan discussing the lack of need for specific lifting techniques and the importance of increasing confidence to bend, lift, and twist in many different ways in order to perform regular daily work and functional activities. Perhaps this could allow me to manage those patients who have firmly held pathoanatomical beliefs with more effectiveness and shift towards a biopsychosocial approach as I utilize the requirements of their daily life to individualize and tailor my treatment to their particular needs.
Overall, I find this to be a very interesting topic and improving my management of patients with NSLBP will likely be a skill I work to improve for many years to come. I think there is a lot of useful information provided in these articles/videos on how we can meet our patients where they want/need to be met in order to improve their outcomes, decrease healthcare utilization, and limit unnecessary procedures such as imaging and surgery. The more I learn on this topic, the more I realize the importance of appropriate communication in the profession of physical therapy and the significant impact we can have on our patients if we are simply able to communicate with them in an effective, educative, and empowering way.