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Good points everyone. My biggest takeaway was that in an effort to meet internal validity, the external validity may be sacrificed, and therefore the treatment parameters in an RTC may not always reflect how an intervention is usually carried out in clinical practice. This is another reason why looking at just the abstract and conclusion of an RTC may not give you all the info that you need to make a clinically sound choice.
Overall, the article reminded me of the importance of using my own clinical reasoning when using the conclusions of an RTC (or any other form of research) when applying them to my patient. Does my patient match the inclusion criteria? Do the methods match how I would use that intervention in the clinic? Does my patient have yellow flags or other traits/presentation that make them a “marginal patient”? What intervention-bias do I have and what intervention-bias does my patient have?
I think the PPT is a good first exercise. It’s not likely to increase symptoms, it will decrease the anterior pelvic tilt that is likely increasing her pain, and work on dissociating her lumbar spine from her hips in a positive way. I also like PPT because they are a good starting point to progress other hip extension exercises.
I’m wondering if you plan on doing manual therapy with this patient, and if so, when you initiated it, what you did, and the frame of reference/set-up for it. (This may be jumping ahead to journal club).
I like your idea of writing down her vocab list, and am also very interested to hear how this played into your treatments with her.
D/D after Subjective (in order):
– Chronic non-specific LBP
– Lumbar facet
– Lumbar discogenic
– Lumbar myofascialD/D after Objective (in order):
PRIMARY HYPOTHESIS: Lumbar facet pain with movement coordination impairment and fear avoidant behavior
– Chronic non-specific LBP
– Lumbar discogenic
– Lumbar myofascialThings to add to Subjective:
– Is she not exercising due to her pain?
– What things about being her mother-in-law’s caretaker aggravates her symptoms?
– What are her goals for PT? Decreased pain vs zero pain?
– Out of her aggravating factors, which thing is the worst? (Sitting vs walking, etc)Things to add to Objective:
– Picking up object off floor –> strategy and pain provocation
– Swing Test
– H&I testing
– If rotation is the worst, is there a difference with rotation in sitting vs standing?
– Hip extension ROMYellow Flags:
– “My back is a mess”
– “Help me so it doesn’t get worse”
– Potentially ruminating about pain if she is not working, no kids, and being caregiver of mother-in-law
– Doesn’t go hiking or fishing due to her pain
– PMH of depressionRed Flags: none
I agree with Erik and Matt’s prognostic factors for this patient. I think her young age is a positive prognostic factor. I also think that she not wanting to have surgery is a positive prognostic factor, as she will likely be adherent with her exercises and splint usage knowing that a surgeon has recommended surgery, which she is trying to avoid. I think overall the patient has a good prognosis – yes she is busy and likely many things she is doing has been aggravating her symptoms, but that also means there is a big opportunity to make an impact with activity modifications.
I shadowed our hand OT for a similar patient who we determined had CMC OA. This patient was a 50 yo female who was a chicken farmer who’s job was to collect up to about one-thousand eggs a day. She also did not want to get surgery and could not afford to be injured or else she couldn’t get paid. I only saw her for the eval, but the hand OT was great about going through activity modifications with the patient, and used specific examples with both collecting eggs as well as other household activities such as opening jars and cooking. I don’t remember what kind of splint the OT gave this patient. The hand OT’s initial HEP for the patient was to write down all other activities that aggravate her thumb so they could continue to troubleshoot activity modifications.
Similar to Erik and Matt, as well as the hand OT, education would be at the top of my priority list for the patient. What I thought was awesome about the article was that the subjects were only seen three times, and they improved a decent amount. The specific brace type and activity modifications were tailored to the patient, but the exercises were not, indicating that perhaps a general strengthening protocol for HEP would be an okay choice for this patient. Matt I agree that after our course series, I would additionally add neural mobs to be performed as well. I would have the patient perform her exercises 1x/day and self-thumb distraction as much as she can throughout her day (when waking up, when stopped at a red light while driving, during commercials if watching tv).
I agree that it is easy to think of chronic pain patients as aggressive, uneducated, and unwilling to change – without thinking about why they are that way – and I think this article does a great job of highlighting their POV. Erik to your question, I think that we have to address both aspects, but will likely spend more time on treating the patient’s biopsychosocial aspects of their pain.
Most chronic pain patients have gradually shrunk their lives smaller and smaller as their pain has dictated them do so. I feel as though our job as PTs is to begin to make their worlds larger and to help make their pain less detrimental to their overall well-being. As Karen stated, the pain is always there, but what Karen has been able to do that many of our patients have not, is to generally still enjoy life and do activities she wants to.
The quote that stuck out to me was “I connected FEAR to my pain […] fear is tattooed into the amygdala. As we go through life these tattoos can be inked in strongly or lightly.” This reminded me of the fear I had with driving after my car accident in Sept, and how I can parallel this to a patient with chronic pain (In the paragraph below, I put in parentheses how different aspects of my experience is similar to a patient who has fear of movement). I feel as though my experience with the MVA helped me empathize with my patients and have a better understanding of some of the thoughts and fears they may be feeling.
When I had my MVA, I was driving and then hydroplaned. It wasn’t as if I did something – I was driving normally and the next thing I knew I was crashing (Onset of pain). The next few months I had really high levels of fear with driving, especially if I was driving at night, in the rain, or on the highway, because this is how it was when I crashed (Fear of movement, especially if it is similar to the MOI such as bending, lifting, etc). The “fear tattoo “was strongly inked into my brain. I drove much slower than the speed limit, and even a gust of wind would scare me (Bracing, making sure to not forwards if picking something off the ground). It got so bad that I got my new car checked out because I was convinced that there was something wrong with my car, when really it was just that I still had a lot of fear and anxiety (Going to multiple physicians, getting unnecessary tests like MRIs). I started to take the longer way to work in order to avoid driving on the highway (Letting pain limit activities you participate in, especially ones that you enjoy). Eventually I began to force myself to drive on the highway at night and in the rain and to not go ridiculously slower than the speed limit (Graded exposure, breaking up painful tasks into smaller and more manageable activities). The more I did this the more confident I felt, but it took a long time for me to really feel like I was in control again.
I agree that the fact that only 20% of participants were actively seeking treatment for their pain is slightly concerning. I wonder what the median pain score for the participants would have been, my guess is pretty low, so there may not have been the opportunity for as much change.
I think that the patients were excluded if they had a positive apprehension test because they likely defined a positive test as a feeling of instability, as the original test describes. That test has been altered so that a positive for pain may be an indicator for impingement, like in that algorithm we have studied.
Overall I thought the article’s methods were solid and it was a well written article. I am not surprised by the findings either. The participants received one thoracic manipulation without any other manual technique or exercise following the manipulation. None of us are doing that in the clinic, we are all following up our techniques with other treatments that will work more directly at their impairments. In my practice, I’ll try a thoracic manip and see if the patient has any less pain afterwards. If so, great, they can likely do something that would have previously been too painful for them to do. And I’ll send them home with an exercise to facilitate thoracic mobility. But its likely not going to be the cornerstone of my treatment for that patient.
Cameron,
You had a lot of interesting points that I related to.
I too find myself asking leading questions so that I can fit a patient into the box I want them boxed in to. I think its because I am still uncomfortable with “gray” and we feel more comfortable when we can put our patients into a category. I am trying to learn to be okay that I may not know what is going on after the subjective, and even after the initial evaluation sometimes. However it then gets tricky to have the assessment and prognosis conversation with the patient to try and explain to them how you can help. Last week during mentorship, I told a patient I didn’t know exactly what was going on (non-specific chronic LBP), and this likely didn’t work well in setting up the patient’s confidence in me. AJ made a good point saying that I should have said something general like “your muscles and joint are stiff and overly sensitive, and we need to get you to move again to get you loosened up and to learn to like motion again.” Super basic and easy to understand from the patient’s perspective, and also doesn’t force me to give a specific diagnosis. It was a really good learning moment for me.
I like that you immediately acknowledge their chart to let them know that them filling out all that paperwork was worth something. I have been breaking out their pain chart like Casey suggested in another DB post, and I feel as though this has been very useful in mapping out their locations and pain complaints. Again, I think this is another way to make the patient feel like they are being listened to.
I thought that this was an interesting article, but very dense and anatomically based. I wish they expanded more on how the findings of the article may dictate how we treat patients in the clinic, however this may be out of the scope of the intent of the article. My takeaway from the article was the complexity of the DRUJ, and how there are numerous structures that need to be accounted for.
The results from the article suggest that the soft-tissue stabilizers can help preserve the kinematics of the DRUJ. I believe this is where we as PTs can help the most, working on improving strength, stability, and proprioception of the soft tissue both locally and then moving further up the chain.
Another finding that I thought was interesting was that the kinematics of the DRUJ were maintained with prox to distal sectioning until the final cut (RULs and TFC). This was evident with both pronation and supination, but only significant with active supination. I would argue that if these structures have been affected by an injury, I would make it my priority to improve the function of these structures before progressing my treatment. Another way of looking at this is that if I felt like these structures were affected by an injury, I may want to get imaging or send them to an orthopedic physician to ensure they are a rehab candidate, because if these structures aren’t functioning, we may not be able to improve the stability of the joint.
Erik,
I think that the subjective is more important than the objective in the first visit. You can always continue to test and check different objective measures, but you only have one opportunity to make a first impression to begin the rapport process with your patient. I would actually argue that the objective aspect is the least important aspect of the initial eval. Sometimes I find myself rushing through my assessment, education, and prognosis with the patient because I spent all of my time on the objective. I am trying to make a conscious effort to stop doing this, because I think the most important things to do in the initial eval are:
1. Build rapport with the patient by showing that you care and listening
2. Reassuring the patient that they are going to be okay
3. Providing them with brief education about what you think is going on and how PT, and their participation in PT, can help their problem.Many times my opening line which is “what brings you to physical therapy today?” seems to backfire quickly, with the patient immediately spewing off a poorly understood but highly detailed and anatomically-driven reason why they are in pain. I have the same dilemma in my mind as Erik does. Do I interrupt the patient because I don’t want to validate their false understanding of pain? Or do I let the narrative continue and gather my information on their understanding of pain, to therefore educate them later? I think there is a middle-ground somewhere, but I’m leaning towards the latter. When it gets out of hand and the patient goes on and on and doesn’t stop, I’ll sometimes (gently) interrupt and mention that I have access to their images, so I can look at that later, but I would like to know more about their experiences and pain from their perspective. This seems to work well, because then the patient knows I will look at their image findings (I don’t always look) but then allows them to begin actually telling their story. My hope is that it gives them validation that I care about them as a person more-so than their MRI.
Something that surprised me was the stark contrast between how long the average time is until a PT interrupts their patient (23 sec) vs how long the patient will usually talk for if interrupted (92 sec). That is a huge difference! After reading that, I thought about how long I wait before interrupting my patient, and I honestly don’t know the answer (maybe AJ can tell you). I hope I wait more than 23 sec, but I definitely don’t wait over 1.5 min. The blog post seemed to allude that not interrupting the patient was the correct way to approach the subjective interview, but I wonder if there is any evidence beyond expert-opinion to confirm this? I don’t even know how they would test for that, but its an interesting thought for me.
The blog post stated that the most commonly used opening phrase was ‘Do you want to just tell me a little bit about your problem first of all?’ Does anyone else think this is strangely worded and too passive? After reading all of the opening lines in the picture, the one that I liked the best was “how can I help you today?” It doesn’t pigeon hole a specific body region, its open-ended, but also direct. Does anyone else have a different opinion? I’m also curious as to what your guys’ opening lines are?
I think that Casey and Jon both have sound clinical reasoning for how they would rule-in/out the competing diagnoses.
I would begin by palpatating his wrist and try to identify if there was isolated tenderness or if it the pain more widespread. More localized pain could implicate fracture, ligamentous injury, or TFCC injury, depending on the location. If there was TTP to a carpal bone, I would combine this with quality of pain, and tuning fork, to make sure that fracture is ruled out. I agree with Casey that fracture would be low on my list since it only occurs when he is tired or with certain WB positions. And I wouldn’t think him carrying a golf bag would aggravate a carpal bone fracture.
I would next perform APR exam on the patient’s wrist, forearm, and hand. Pain with AROM into wrist extension and/or wrist ADD would increase likelihood of ECU, however doesn’t necessarily rule out the other structures. PROM into flexion and/or wrist ABD would further increase likelihood of ECU or possibly ligamentous. The most important finding to me would be resisting wrist ext and ADD in their lengthened position, if resistance increases the patient’s pain, that would increase the likelihood of ECU.
Next I would see if compression or distraction aggravated his symptoms. I would expect distraction to increase the patient’s pain only if it was a ligamentous injury, so if distraction increased his pain, this would help me rule this in.
Lastly, I would use special tests to try and rule in my primary diagnosis or rule out any competing diagnoses. I would use STs such as the supination lift test, the ice cream scoop test or ECU synergy test that Casey describes for ECU involvement, or diagnostic US for TFCC involvement. The press test would be a great test to use to rule out TFCC, as it is 100% SN.
Subjective Questions
– More specific location of symptoms – dorsal or palmar side?
– MOI? Gradual, traumatic, insidious, increase in activity?
– Numbness or tingling?
– Weakness in hand? Change in grip strength or poor fine motor skills?
– Any elbow, shoulder, or neck pain?
– Hand dominance?
– Joint noises?
– Stiffness?
– Any pain in morning or night?Objective:
– Functional Assessment of Aggravating Factors: lifting box, WB through UE (does it matter how he WBs?), swinging golf club or demonstrating with something else (does it matter how he holds the club, is it during a specific part of the swing?)
– Screen out cervical and elbow
– APR examination: wrist flex/ext/RD/UD, elbow flex/ext, forearm pron/sup
– Grip strength
– Palpation
– Joint assessment of carpal bones
– Distraction vs compression
– Special tests depending on subjective and objective info, however would guess I would want to do:
— TFCC grind test and press test
— Ligamentous testing
— Instability testing
— Shear testingI have no clinical pearls of wisdom to share unfortunately. I’m hoping I’ll be able to see some more elbow, wrist, and hand pathologies in the second half of my residency. As an inexperienced hand/wrist clinician, the article with the flow chart that Laura posted would be extremely helpful in deciding which special tests to do based off which objective findings, which would hopefully help with diagnosis and treatment. One of the articles stated that the wrist and hand have a much less likelihood of referred pain compared to other regions, so I would rely heavily on palpation to guide my differential diagnosis.
I thought that the chart that Dr. Boissannault provided us with is a great tool to utilize in the clinic. It is very simple and it highlights the most important questions to ask patients and listen for when we have red flag concerns. Something I have been working on is asking the right questions depending on which red flag pathology I am concerned with, rather than asking the patient every red flag question I can think of, with no clinical judgement as to why I am asking each question. The chart helps clinicians be succinct yet thorough and cover our bases. I also really like that it provides the medical tests you may want to recommend if you are referring back to the physician – that way it helps avoid unnecessary testing and may help speed up the referral process.
I’ve already incorporated using the chart into my clinical practice, here are two examples from today. I have a patient who has been diagnosed with b/l knee OA and back pain whose pain is 10/10 and can’t find any positions of comfort. She speaks Spanish which makes communication difficult, but she said she had gone to her physician and had lab work done. When I called her physician’s office, I was able to voice my concerns and ask specifically which tests had been completed, and helped initiate a POC for the patient. I was also able, to the best of my ability, ask her red flag questions that I was able to document in the note I sent to the physician.
I have another patient who insidiously but quickly had a large increase in RLE pain > LBP. He has a positive Slump and SLR, but what concerns me is that he has very noticeable, multilevel myotomal weakness L2-5. He also has N/T that goes into his anterior thigh and shin. I was most concerned with cauda equina, due to age, weakness, N/T, aggs and alleviating factors. Using what I learned in the class and the chart to help, I was able to ask him very specific questions about the numbness and tingling, and B/B changes (and I was more specific than just asking if he had B/B changes, as Dr. Boissannault said that urinary retention was the most significant finding). Luckily the patient had already had an MRI, but it has helped keep me on my toes to what to look, listen, and ask for.
There is a joke in my clinic that I think all of my patients are dying of cancer. I think being a new grad and being in a residency where red flags are talked about often raises my concerns maybe more than they should be (better than the opposite I suppose). The class and the article helps me be more confident in my ability to detect red flags and ask the right questions to ensure that my patients are appropriate for PT.