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Cam – Good call about the Pitt and Ottawa Knee Rules, I agree with that. I know the Ottawa Knee Rules aren’t meant for children, but I think she is old enough that they would apply to her. If there are any positives for the Ottawa Rules, I would definitely recommend an XR. If they are all negative, I still may recommend one anyways based on what I find. Her age and demands of her sport and risk factors enough for me to be highly suspicious of a fracture.
Casey – great list. I didn’t think about menstrual stuff but do think that is important to ask.
To add to Casey’s questions: did she land the back handspring well? Was there a twisting MOI? Is this a move she has done 1,000x or is this new to her? Has there been a fast increase in activity level? Is she under stress from parents or coaches to be a specific weight? I’d break out the tuning fork and see what happens.
With kids I do a lot of “show me” rather than asking a bunch of questions because it is hard to get good subjective info from them. The other thing I do is compare to the other side when doing objective testing so that they know what normal is. Lastly, case-by-case basis, but I’ve had some awesome parents who can tell me what hurts and what is abnormal just from seeing their child move now vs. prior to injury. I always try to have parents present at least in the beginning to help with adherence to HEP and to help explain the why we are working on X, Y, and Z and how it’s going to help.
I thought that the findings of the study were interesting, but do they change my clinical practice or how I think about manips? No not really. It may help with patient education, so I when I tell them why I want to do a manip I can say “there is research that shows that after a manip there is an increase in feel-good hormones, which will decrease your pain and give us a time-frame to work on some exercises to get you stronger.” I already basically say this, but now I can say it more confidently and list off a couple specific hormones to make what I say sound smarter and maybe improve patient buy-in.
I will admit I am likely biased being taught at UF by Steven George, Mark Bishop, and Joel Bialosky who are some of the bigger names when it comes to pain, especially in reference to manual therapy and psychological factors. You guys remember the crazy chart in the Manual Therapy (and probably others) lecture titled “the mechanisms of manual therapy in the treatment of MSK pain: a comprehensive model” (attached). My professors never attempted to have us memorize that insane chart, but rather emphasized that there isn’t a singular reason why manual therapy helps, it is a combination of neurophysiological factors.
With the study itself, I wondered if the changes seen were due to the manip itself, or was it the positive expectation from the manip? The study didn’t seem to look at that, but I wonder if they had captured patient expectations prior to the manip, would there have been a larger change in chemical markers in those who had a positive expectation that the manip would help? This goes along with what Laura was stating, where taking patient preference into consideration will likely improve outcomes, especially when it comes to manips.
In reading the sham protocol, it didn’t seem like a convincing sham. “The clinician conducted the same basic steps as the SM, localizing the appropriate vertebral landmarks but without moving the individual or carrying out the final thrust procedure.” If the patient wasn’t even moved, was this a good sham? I don’t think so.
Erik, I was thinking the same thing. Although a proper PT cervical and neuro screen was performed to rule out a cervical referral, maybe the NP saw something in her exam that led her to making this decision. Although a PN was sent, who knows if the NP actually read it? I would call the NP and ask why the decision was made to order the MRI (if you could get access to this provider’s visit before making the call, that would be even better). I think first of all this is good for developing relationships with referral sources, and also may lead to a good conversation with the NP, likely displaying good clinical reasoning skills on your end for questioning the necessity of the MRI ordering, and demonstrating that improvements have been made with PT thus far.
I do agree with everyone that my immediate reaction is to think the MRI is definitely unnecessary and if given would likely lead to pain catastrophizing, mis-education, and nocebo. In regards to patient education, hopefully by the third visit I would be able to use a test/treat/re-test to demonstrate and then further educate the patient that PT is and can continue to help the patient’s pain. I would educate the patient that an MRI will likely lead to injections and possibly surgery, and would stress that surgery would be a last-resort option, especially with her young age and occupational activities she has to perform.
Lastly, like someone mentioned before, I would educate the patient on tissue healing times and time for muscles to hypertrophy and improve in strength so that the patient has realistic expectations for the time-line of the recovery process. I would also add that with the patient having to continue to her job requirements, that that will make the recovery time even longer – not to discourage the patient, but to make sure her expectations are realistic and you two are on the same page.
Tibial stress fx would be higher up on my differential diagnosis list given the brief subjective report. I agree that more info based on training volume and progression of training would be helpful in how suspicious I am of a stress fx. Although it may not necessarily change anything on my differential list, I would ask some questions about any past running injuries, nutrition/diet, and if he participates in any weight training, as these factors could potentially lead to an increase in likelihood of stress fx.
I think that the article’s flowchart is very helpful and to me makes a lot of logical sense for how to go about imaging. In this patient, I agree that I would recommend an x-ray first. If negative, I would treat for 2-3 weeks and then get a repeat x-ray. In the meantime I would speak to the referring physician about getting an MRI, so that this timeline isn’t dramatically lengthened. Since this region is not a high-risk site, I would not feel that an MRI is required immediately. Erik, I wouldn’t go the ultrasonography route at this point. I didn’t think the research was solid enough that I would recommend it before an MRI, as it has low specificity, so there could potentially be a false positive.
As far as my treatment approach, if I am really thinking there is a high suspicion of a stress fracture, I would probably give the advice for cross-training so that he can continue to work on his CV endurance. I would also see if I could make any modifications to the LE chain that could change his pain. Based on this I would work on strengthening, motor control, etc of whatever extrinsic factors I felt I could improve. I just don’t think any modification would be powerful enough for me to recommend him continuing to run, especially since his symptoms have gotten worse enough to be aggravated with just prolonged standing. Do you guys agree with me on this, or would you try to work within his pain so that he can complete his half-marathon? I would just be worried about making his stress fracture worse and potentially lengthening his recovery time afterwards. I have literally never treated a runner at my clinic this year, so you all may have a different perspective than me on this.
Matt I agree that my general pharmaceutical knowledge is limited even after taking an introduction course. However my takeaway is that there are numerous ways the drugs are consumed by the body, and that there are a variety of potentially harmful side effects and negative drug interactions. I could better my practice with being more familiar with the different classes of CV medications, knowing which ones specifically affect blood clotting, or which ones cancel the blood clotting effects out from each other.
When reading the article, it was comforting to see that the majority of PTs were able to list 3 conditions in which NSAIDs were appropriate, and 3 conditions in which NSAIDs were contraindicated. I also found it helpful that most are also recommending their patients speak to their physicians or pharmacists about drug interactions, and that the majority are documenting these conversations.
Like all of you, I always say something like, “it is not within my scope to specifically recommend medications, however taking an anti-inflammatory medication may help with the initial healing process in a recent injury.” If I know they are on multiple medications, especially ones that may affect blood clotting, I always urge them to contact their physicians to ensure that this is okay (CYA). Cam I think what you say is appropriate, and I think I could be better about going over the potential side effects like you do with your patients. To your point about over half of PTs making recommendations with insufficient knowledge, I think ensuring we are urging them to get the okay for their physicians makes this less-bad of a finding.
I don’t think its outside our scope of practice to make general recommendations regarding stress/depression/sleep, etc. If this was, we would unnecessarily refer out for every single patient. I think referring out is more appropriate when we recognize that a situation is beyond our expertise. I was shadowing our very experienced hand OT yesterday. The patient had been in a traumatic MVA and after talking to her about her accident, it was apparent the patient was suffering from depression and PTSD. The hand OT did an amazing job of recognizing this and urging her to seek counseling, and also referred her to PT because the patient was having back pain from the MVA as well.
Hey Casey,
Good job today. Looking at Myra’s post, and also in what we talked about today, can you post the article that you looked at that differentiated hip from back symptoms?
Hey everyone, sorry I’m late to the party.
Top Subjective Differentials:
– Hip OA
– Glute med/min tendinopathy
– Lumbar referred pain (DDD, discogenic)
– Lumbar radic (Difficult to say which level, esp after looking at pain diagram)Exam:
– I would start with a functional exam looking at gait, SLS, swing test, step-ups. Then I would rule out lumbar spine with APR exam. I would perform a neuro exam as he has LBP with lower leg pain as well. Then I would go to the hip.Yellow Flags:
– Completely stopped exercising (fear of making it worse)
– 20 year history of LBPRed Flags:
– Constant pain that is also painful laying in bedAfter Objective:
– Some conflicting things here. Some things seems very glute med/min tendinopathy-like however location of symptoms is strange, and definitely wouldn’t expect back movement to reproduce this pain if this was just a tendinopathy. So I would think that hip OA would move higher towards my differential list with location, lack of hip mobility, and pain with WB.– His fear and intolerance of WB is slightly concerning to me. Also somewhat concerning is that hip distraction increased his pain.
– I would have done a neuro screen (reflexes and myotomes at a minimum) and PAs to lumbar spine to assess for pain provocation. Also would have also done a traditional SLR. Since he had high irritability, these would have been good things to do to rule out while not aggravating his symptoms too much.
– Day One: I know this is really low-level, but I would probably go with some LTRs (lower trunk rot). It looks like he is not moving his lower back at all, so this could help improve some general mobility here while staying in a NWB position. I really like Cam’s suggestion of a stationary bike, as this would not likely increase his symptoms while giving him some sort of exercise he can participate in.
It depends on if I feel like I have developed a good rapport with them. But yes I have. I think this is where the “art” of PT comes in, because you have to read your patient, know what motivates them, know how they are motivated, and give them the education that they need in a way that will work best for them.
I recently had this conversation with a 16 yo female patient and her mother. She is a super interesting patient, as she has PFPS and is an Irish Riverdancer (I don’t come across these types of patients often in Woodstock). She has to dance for numerous hours in a row multiple days in a row. She is doing a lot better than before, however will still have a 3/10 pain by the end of several days of dancing in a row. She and her mom are a bit hyper-vigilant, as they are really afraid this pain is going to return if they don’t do everything right – including taking her pain medication before and after every practice religiously. She definitely has a psychological dependency on her Ibuprofen. As she is improving, I suggested her weaning off the pain meds. I can tell she is using them as a mental crutch, because she is so fearful that if she doesn’t, she will go back to her pre-PT self. She is a very motivated and works hard, and I know she is adherent with her HEP. I praised her on how hard she has worked to gain strength and mobility to improve her symptoms. I told her that it is normal to have some pain with that much dancing, and as long as she is listening to her body, continuing her exercises, and icing, that she will continue to improve, even with taking less and eventually no pain medication.
With her I knew I could be direct, but I wanted to highlight how hard she has been working. With other patients, I may have had to be more playful, others I would have to be more in-direct. I am no expert on this, but I think this is such an important skill that we have to work on.
I agree with a lot of the things that have been brought up. I do have some further questions that I would want to find out about before I give specific recommendations:
– How has this patient been taking the Ibuprofen? Is he on a consistent regiment where there is a therapeutic dose, or is he taking the pain medication as needed?
– Does he have a history of GI issues, blood clotting issues, etc? Although it seems the physician is an advocate for him to decrease his pain medication, after reading this article, I would want to know more about his PMH before giving him any specific suggestions? If there is a significant PMH, this may warrant a conversation with the physician.I personally wouldn’t spend time trying to get the patient to switch Ibuprofen to Tylenol. To me that is just something else for him to become reliant on, and since his pain isn’t an acute inflammation response at this point, it doesn’t matter whether he is taking an anti-inflammatory medication or not. Although Tylenol has a slightly decreased chance of GI issues, the article seems to state that this is not vastly different than an NSAID.
Most patients don’t want to be on pain medication, so I would try to get the patient to admit that he doesn’t want to be on pain medication his entire life. It might not have to be a lengthy discussion or point of education if the patient begins to feel better after a couple weeks of PT. Similarly to what was mentioned above, if we can give the patient movement strategies to decrease his pain, and emphasize that he can do these if he is experiencing pain, he may naturally try to wean himself off the pain medication. If he does not and truly does have a psychological attachment to the pain medication, then I would go down the education/weaning off road.
Jon and Cam, I agree that the chronic pain patients with a psychological attachment to their pain medications are very difficult to successfully treat and to have them wean off pain medication. Unfortunately I don’t have an all-star strategy for this. In general with these patients, the goal for me is more based on improving their function rather than their specific pain levels. I try to emphasize their victories and give them a lot of praise for going out of their comfort zones and trying an activity or doing something for longer before pain onset. I think once you have developed rapport with them and they feel like that are improving, having them experiment and take one less pain pill a day, or waiting until later in the day to take it, is a less daunting task to them.
Erik, good point. In reading this article, it highlights the vast differential diagnosis options there are for immediate referral, non-immediate referral, or treatment only. There are so many possibilities for the pain generator and pain intensifiers in the TMJ, so a solid subjective history is really important. To me, it makes sense that in this patient’s case, and in many others with long-lasting TMD, that there would be many yellow flags, just based on how frustrating it would be to have pain when you talk/chew, lay down, etc. The article discusses how pain-science education can decrease pain and disability in TMD patients with chronic pain. I bet a PhD candidate would really connect with this, and it would probably be easy to give her resources for her to further educate herself on this topic, and then to further discuss with her. (Speaking of: if anyone has any favorite YouTube videos or websites for this, definitely post them, as I would like to build my library of these to help use for patient education.)
Erik I partially agree with you, with the recent increase in pain being after a dental procedure and pain with eating/chewing. However I would bet that there is a large cervical spine component to this patient’s case based on her history of MVA, HAs, neck spasms, occupation (prolonged sitting…possibly postural component). Obviously there is a lot of info we don’t know to help our differential diagnosis.
Something I don’t think we’ve brought up in terms to questions for the dentist, is why was she having the procedure in the first place? Was the procedure an attempt to decrease her TMJ pain, or was it completely unrelated? Was it trying to fix an anatomical variant the dentist identified with her mouth/jaw?
I agree with both of you. I would ask her if she notices a correlation between stress and her HAs or jaw pain intensity or frequency. This would be a good gateway into how she manages stress and maybe help her understand that her chronic pain is more than just a biomechanical fault that needs fixing.
I also want to know what she does differently due to her pain. Does she avoid hard foods when her jaw hurts? Is she eating a soft/liquid diet? I want to get a sense of how much the pain interferes with her life. Is she comfortable with some pain if it doesn’t get TOO severe or irritable, or does she stop everything if there is any pain? This can help me get a sense of her fear of pain, and can lead to the start of a good pain science education discussion.
I wouldn’t have thought about asking the dentist about the procedure and about his/her opinion on the patient’s pain. I’m curious, what specifics of the dental procedure would you want to know about, and how would this help you in the diagnosis and/or treatment planning for the patient?
Interesting article. In my experience, I have had a lot of success with using isometrics for acute pain relief, especially within session. I have seen this in a variety of muscles and joints. My typical implementation is using them in the painful region of AROM – so for instance if someone has pain with shoulder ABD at 70 deg, I will have them hold the isometric either right before or at the painful ROM. This way I am targeting the muscle where it is most aggravated for acute pain relief. Then I re-check and see if the pain in the painful ROM has decreased, if so I progress to AROM exercise.
In addition, I am more apt to use an isometric if AROM in painful, and the pain increases with increased reps of the movement. In previous tendinopathy articles, they tend to use a “no more than 3/10” approach, so if a patient’s pain is above this or increases quickly, I stick to the isometric. This commentary mentions how acute pain response is not the ideal indicator for response to treatment, and rather pain-rating the next day is a better indicator. I agree with this, however in the real-world setting, I find it difficult to properly educate patients on this, and to have this be reliable. In a low-irritable patient who is not fearful of pain and has a good understanding of the management of a tendinopathy, I think having the patient work through some pain and having them tell you their response is a good choice. But if the patient has high irritability and does not quite understand the concept of “hurt does not always equal harm”, then an isometric is going to be my treatment of choice (with further education to help them understand these concepts).
The commentary helps me remember that pain during exercise is okay, and that it is oftentimes essential to proper healing of a tendinopathy. It reminds me to ask my athletes or individuals on how they felt the day after treatment. I think HEP flexibility with these patients is really important, and educating them on which exercises to perform based on their response to treatment is really important. For instance, if the patient had minimal pain after a treatment, it would be just fine for them to continue their exercises. But if the patient had 6/10 pain the day after a treatment session, then it would be a good idea to regress the exercises to a less-painful version while they are at home. Helping patients understand progressions and regressions would be really helpful in their own management of their symptoms, and I believe makes them feel like they have more understanding and control over their rehab.
1. List your differential diagnosis after the subjective exam. Does this change after the objective exam?
– CAI
– Ant ankle impingement
– Peroneal tendinopathy
– High ankle sprain2. List any yellow or red flags you’d consider this case.
– History of ankle sprains
– New injury occurred during PT
– Avoiding recreational activities3. Are there any components of subjective or objective exam you would have included
during the IE to help clarify your DD list?
– I’m generally wondering if her new injury feels familiar to her or if it feels different from past injuries
– Is she hypermobile in other joints/high Beighton scale indicating general instability?
– How far into med school is she, and is this impacting her schooling at all? (like walking around hospital)
– Does she want to return to dance? What are her goals?
– SLS
– If any symptoms with single leg squat, does this change with ankle positioning?4. What would be your manual, exercise, and educational interventions are for IE? Does her past treatment influence interventions during day 1?
– Manual: G-V TCJ manip if patient not fearful. If she was or you wanted to wait until further visits, I would do a posterior MWM into lunge if patient could tolerate, and then show her how to do this for HEP.
– Exercise: I would start fairly gentle with patient to improve her confidence with exercise again. Probably SLS and other balance exercise without any dynamic components. Also ankle eversion strengthening in non-painful AROM.1. A question to determine the patient’s severity and irritability would be very important, because it will determine how extensive my initial eval is. If the patient has really high severity and irritability, I will likely not be as aggressive during the initial eval, because I don’t want them leaving with so much pain that they can’t talk or eat afterwards. Then they won’t come back.
2. Description of pain and other symptoms. Is it just pain, or is there clicking too? Is there ROM loss, or is it normal/hypermobile? This will help with my DD and to rank my initial hypotheses.
Erik I think you’re onto something comparing this to the subluxation cycle.
Cam, I never would have thought of the homunculus model as a reason why the hand may be different than other joints, but I think its a great point.
I really liked the second article posted and how it uses ACSM exercise guidelines in its prescription for its own CMC OA exercise guidelines. It reinforces the idea that the hand/thumb is not completely different than any other joint in the body, although I keep on thinking that it is (most likely due to lack of treating it). I also liked that it was biomechanical in nature, but then provided some really key concepts to help with exercise prescription. It would be interesting to see if they implemented this exercise prescription in a RCT similar to what Cam referred to.
My last thought is that as I’m reading these article about CMC OA, I’m surprised by the low number of visits the articles are reporting. Is this because education is such a big component of this pathology? I would think even if this is the case, that these educational concepts would need to be reinforced several times for them to really stick.