[Justin Bittner]

Some of the changes I noticed was the use of the classification system to grade the effectiveness of treatments. In regards to the interventions, previous grade A interventions form 2008 (cervical manip, strength/endurance exercises, and pt education) were no longer grade A interventions for the classified groups.

I also found it interesting the amount of modalities that were listed. Previously in 2008 electrical stimulation was never mentioned and laser was only mentioned in one study that found it ineffective. However, in the updated CPG it they were both mentioned numerous times from many studies and were found to be more effective than cervical and scapular endurance exercises when treating chronic neck pain with mobility deficits. However, these treatments were not recommended for patients with headaches or radicular symptoms.

[Justin Bittner]

Nice case Erik. I think that your case highlights the importance of continued assessment and reassessment throughout care. “Peeling away the onion layers” and as things begin to resolve in one place, continue to look for asterisks that could impact your primary diagnosis. This has been one of the biggest things I feel I have gotten better at since residency started.

[Justin Bittner]

Nice case August. One of the clinicians at PRO treats a lot of pitchers, including professionals. Part of his exam for every pitcher is hip ROM assessment. He always talks about the hips and core being the foundation for the rest of the pitching movement and any limitation there must be treated. He has been working on research looking at shoulder injuries and their correlation with ER loss of stance leg and IR of lead leg. He has said there is quite a correlation between shoulder injuries and ROM loss at the hips, as well as, hip weakness.

It is particularly hard to consider assessing further regions away when you have decent asterisks for the upper quarter.

Cool case though. I thought it would be nice to talk about some cases we have had that required us to think outside the box (things we may have missed without residency).

[Justin Bittner]

This is a good commentary. One thing that was mentioned in the article was that researchers use pain based special tests as a yes/no test not accounting for those subjects with a “maybe” answer. Which is what we see a lot in clinic. Another point from the article that I liked was “The best clinicians use fewer tests and make decisions on refined data”. Meaning that the best clinicians can use less tests as they are able to better filter subjective/objective findings to lead them to a diagnosis. This points in a way to what Mike Reiman talked about at the course 2 weekends ago. Saying that the most important thing that residents and fellowed achieve is a better ability to take a subjective history, leading them to a diagnosis.

Since starting residency, I primarily use special tests to rule out things on my hypothesis list that is still unclear based on special questions. And then use special tests to confirm a diagnosis. Often times I use one or two as an objective asterisks carried over from visit to visit. Ideally, I like to have a functional test, ROM, resisted test, and special test. So initially I may use the special test to help with a diagnosis initially and then use it as a retest throughout their care.

[Justin Bittner]

Funny, I said I had not had any patients inquire about PRP and today two different patients ask me. This certainly seems like a question we are going to be receiving more often over the next year or two.

[Justin Bittner]

In addition to the proprioceptive variables with balance training, I found the pictures highlighting the ankle position during biking and nu-step. I generally have all patient’s do some kind of warm up and I know I don’t typically put much thought into their ankle position during biking. Will definitely take note of this during warm ups for my ankle patient now.

I would be curious to here anybody’s thoughts and or experience with the braces from the article as I have little experience.

[Justin Bittner]

I have not really had any experience with patient’s having these injection or asking about them. I know the literature is somewhere in the middle regarding its effectiveness and it’s the latest buzz as far as injections are concerned.

I can tell you that my brother did a sports medicine rotation with the team doc for the Pirates/Steelers and he said he gave them out like candy (4-6 patients/day getting PRP injections). He verbalized how effective he had found it in his practice. So, that is my only input. It is being used a lot by some (one I know of) of the sports med MDs.

[Justin Bittner]

I have used the images a time or two from the research in JOSPT from 2013 using fMRI to show reductions in blood flow to pain areas of the brain following thoracic manipulation. My explanation was no more than, “the images show reduced activity in the pain areas of the brain following this technique”. Short and simple. Mainly because there is not a chance I could explain it in depth.

[Justin Bittner]

Interesting case Katie.

1. I currently have one pt with CRPS of her R foot and ankle. She is a 23 y/o female that tripped chasing her cat many months ago. Things that have been beneficial for her are mirror therapy, graded exposure (I have messed up on 2 occasions with this and flared her up), thoracic physiologic mobilizations in sympathetic slump positions, thoracic manipulation, deep pressure with physiologic movements (this has progressed as her sensitivity to touch improved).

Some asterisks I have used were skin temperature at 1st/2nd web space, medial and lateral malleolus; sympathetic slump, active and passive LE movements.

2. I have not had an emotional parent and child at the same time. This is a tough one. I feel like I would probably, as August said, try to listen to them and their concerns, asking their goals, and explaining clearly what I have to offer them. Sometimes this can be enough.

3. If symptoms continue to worsen, I would likely try to get the MD on the phone to explain the situation with a couple weeks depending on speed of worsening symptoms. I would like to say I would recommend sympathetic medication or psych eval like Scott mentioned even though I find these conversations still difficult to have. I generally try to say what I have to offer musculoskeletal wise and how other systems can effect pain and the nervous system. I try to spin it in a way sounding like I can help “xyz” while your physician can help with “abc”.

4. With my current pt I have used thoracic manipulation. She demonstrates positive sympathetic slump that is improved following thoracic manipulation. I have also found the physiologic mobs in sympathetic slump to be just as effective for her. I made sure I explained to her day one that the thoracic spine may likely be an area of treatment so she was more onboard at follow-up visits.

[Justin Bittner]

1.
I had to look up why left-handed people were excluded from the study. Apparently, lefties use both hemispheres for certain tasks that righties only use one hemisphere and can throw off results quite a bit. Sorry to the 10% of lefties with fibro this article doesn’t apply to. As already mentioned by Auggie-bear and Scott, it is rare to have a FM patient without psychosocial yellow flags. Though I feel this can be applied to most FM patients that would be one thing limiting its applicability.

2.
It is extremely difficult to get a patient to buy into the use of aerobic exercise for pain. The benefit of using this article as a reference is: A) the parameters are simple and allow the patient to have some control and B) the pictures of the fMRI signals can be used as a visual aid assisting with potential buy in.

3.
I have had one patient who I had bought into pain science and started seeing a conselor and was seeing significant improvements in pain and function. I know I talked to be about having a sensitized nervous system making manual therapy difficult.I talked to her about using 15-30 minutes of moderate aerobic exercise on the treamill (she liked walking) to lower her CNS sensitivity. This gave us a window to perform some manual therapy and allowed for specific therex to follow. This was a unique patient that I was able to get buy in at eval. I think what helped so much that day was relating her story to how she interpreted pain. She really seemed to “get it” when I could relate some pain science to her specific story.

I have certainly failed a lot at getting buy in for these patients. But I think what was most helpful in this case was getting buy in early by relating her specific story to pain science. Once I had buy in and her trust, it opened more opportunities and her willingness to try what I had to offer.

4.
I’ll try to tease out if they think FM is related to their complaint and go from their. I feel like i Have a lot of patients that circle FM on the intake and write “possibly” or “not diagnosed” beside it. So, if its circled, I’ll ask them why they circled that and how they think their pain correlates with that. I’ll try to tailor the rest of my eval based on their response. Certainly, if they think it is related to their current complaint, it absolutely needs to be addressed based on their current belief system.

[Justin Bittner]

1)Any other exam techniques you would have performed?

Like Scott, I may have checked patellafemoral glides for pain and mobility. It may have given you an additional asterisks to treat and monitor. I also likely would have check her ability to perform a SLR with resistance and compared bilaterally for quad lag or resistance.

2)Any other treatment you would provide?

Due to the lack of knee extension, I likely would have performed the screw home mobilization Scott mentioned and followed that up with passive physiologic extension with OP, if tolerated. Since this has been going on for awhile, coupled with tenderness throughout HS and (+) neurodynamic findings, I may have performed STM to posterior chain in a position of knee extension.

Your therex selection I thought was good. I may have given a bridge with progressions as appropriate to incorporate lumbar and LE strengthening together. You may have given additional exercises for her HEP that did this as well, as you therex in clinic did but just thought I would mention it.

3)Does anyone have specific parameters they use for return to run/walk program?

Unfortunately, I have seen very little of these patients and have not had to answer this question for patients very much. However, the few times I have, I have given them the JOSPT patient perspective (attached) and explain a slow progression to prevent re-occurrence of pain. I like what Scott posted as it is much more specific and is certainly better than saying “progress slowly”.

This is also a good blog post by Chris Johnson and Nathan Carlson on return to run as well:
http://www.running-physio.com/when/

4)I have not used manipulation with this patient as of writing this. Articles describing the use of manipulation for pnts with knee conditions usually describe the benefits stemming from increased quad and gluteal activation reducing PFPS or improving pnts muscle activation following ACLR. How do you think this case varies from those presentations and how would you have you added lumbar intervention to treatments if at all?

I think I may have added a thoracic manipulation at some point due to the the (+) slump to see if that made an improvement in that asterisks. This is likely, primarily, due to the research I did with Aaron.

I have added lumbar manipulation to 2 patients I can think of with knee pain. Both of those cases did benefit from the manipulation and had resolution of symptoms. I felt I added this late in their care as their pain persisted. So, to say I would have added manipulation only 4-5 visits into this patient’s care, I would probably be kidding myself (although I would like to think I would’ve at least thought about it based on their hx of LBP).

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[Justin Bittner]

I think one thing this article points out that I have tried to utilizing the last couple weeks is to celebrate the small victories with patients. This is more important, obviously, with certain patients. So, along with making goals, we should be empowering patients and praising them on their successes. For example, instead of saying “great, you’ve met your goal of being able to go up your steps”; follow that up with “I can tell you have really been working hard at home”, “I’m so happy you have been making noticeable gains every week”, “can you believe you couldn’t even put weight on that foot 3 weeks ago?” etc.

[Justin Bittner]

I did some research and apparently this was “somewhat” common back in the day. The body creates a “false joint” after soft tissue invades the acetabulum. Good thought about the post menopause and blood supply. I hadn’t thought of that.

She had decreased standing time on R and demonstrated a compensatory trendelenberg. Also lacked hip extension at terminal stance. During squat she compensated by wt shifting onto her unaffected side loading that hip more and increasing hip flexion on that side. She did not demonstrate posterior pelvic translation either with squat. I had not thought of during femoral nerve tests, mainly because she had no radicular sx or neurogenic type sx. But since I did a slump, I could see why that would be beneficial. I did a standing rotation test but did not mention it above. I find it useful as well.

I primarily treated her hip, however, she had low back complaints. Although the hip was the driving factor I felt it was worth addressing her back as well. Treating proximally potentially to provide positive neural input. Similar to the article Eric posted about the hip and back complaints being intimately related. I gave her exercises such as self mobilizations to improve hip mobility. I gave her hip strengthening exercises in modified WB or open chain to reduce compressive force (since she was on her feet all day with compression).

[Justin Bittner]

The use of compression proximally can reduce the nervous systems perceived threat distally and allow you to move into ranges previously unattainable in a non threatening way. I took a neurodynamic course on medbridge where this technique was used. I have had some success in clinic using this technique; although I have not used it much. Not to say it would work with your guy, but it is something to try if attaining positions for mobilizations is difficult. However, it may be just as beneficial to mobilize elsewhere as we talked about last VOMPTI course.

[Justin Bittner]

Wow Scott. Crazy case. Sounds like this guy’s nervous system is really ramped up. A couple thoughts I had at first in addition to what you have mentioned. I think the aerobic exercise program you have him on is a must. I also thought aquatic therapy could be beneficial. I usually don’t recommend aquatic therapy but for this dude, the tactile stimulation while performing movements could be potentially beneficial. I also thought, wearing a compression shirt under this shirt for some compression reducing neural sensitivity. We do this in children, it could be beneficial for him. Also, when performing nerve glides in the clinic, you could use compression to the proximal arm using a voodoo band or even theraband.

Those were my first thoughts in addition to what you already have going on with him. Let me know your thoughts. I’ll let you know if I have any other thoughts.

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