[jeffpeckins]

1. What are your top three diagnoses based on the subjective information? (ranking order)
– Dural irritability in TL region
– Disc referral
– Myofascial strain of musculature in TL region

2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
– Dural irritability: bending over increases pain, slumped posture increases pain, braced posture with functional movements, MOI
– I believe that her dural irritability has led to concurrent myofascial symptoms

3. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient?
– Interested to know which movement recreated shoulder blade pain with Slump
– H&I testing and lumbar quadrant testing
– Resisted lumbar/thoracic movements
– Myotomal screen

4. How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this
patient regarding prognosis?
– I would discuss how after the initial injury, the nervous system got irritated and tensed up. Now that it is tensed, it doesn’t want to move, as movement is now going to be perceived as painful. This likely has impacted the muscles, since the nervous system didn’t want to move, now the muscles are also tensed and irritable as well. I would give advice that it is important to get the muscles and nerves moving again, and that your job is to assist this movement in minimally-painful ways (finding positions of comfort). I would also re-assure patient that nothing is permanently injured, and that it is safe to move and will not cause further injury, even if there is pain.
– I believe this patient will have a good prognosis based off the info given. She chose PT rather than a completely passive treatment. She is motivated to return to doing more at work and playing with her daughter (also important that she is still working). She is probably just fearful of movement at this point.

5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie regarding patient education, manual therapy techniques, therapeutic exercises, etc.
– If STM is not too painful, I may begin there to get her musculature to relax. Then I would find positions of comfort, likely working into lumbar extension with prone press-ups or something to that effect. I do Slump nerve flossing (whichever actions do not reproduce any pain). If not too irritable, I would do open-books with short lever arm to the L, as the R seems to be more irritable.

[jeffpeckins]

Did anyone else find this article difficult to read and follow, or was that just me? To begin, I don’t like the phrasing of arthroscopic partial meniscectomy (APM) vs PT to determine if PT is noninferior than the surgery. Why can’t it just be PT vs APM, with the possibility of PT being BETTER than surgery, not just “noninferior”? Not only do I think that this already puts PT in a bad lighting, it just makes the results and conclusions that much more difficult to interpret, with double-negative jargon such as “results did not demonstrate noninferiority at the 12- and 24- month time points.”

One thing that really struck me was the adverse events section of the paper. It reported that there were 9 participants in the APM group and 8 in the PT group that suffered serious adverse events (CV, neurological, or internal medicine conditions, venous thromboembolisms, or repeat knee surgery). I wasn’t able to gain access to the supplemental content which apparently stated what each adverse effect was, but what was PT doing that resulted in EIGHT serious adverse effects? Were people who switched from the PT group to the APM group, and then had to undergo another knee surgery included in this category? Can anyone else explain this?

The PT groups’ exercise protocol seemed to all be the same and all participants received the same treatment. Does anyone else agree that the PT groups’ results may have been different if the physical therapists were able to tailor their interventions to the patient based on severity, irritability, and patient tolerance for specific exercise?

Looking at the results and discussion, it seems to say that at 3 and 6 months, PT and surgery were comparable, but at 12 and 24 months, surgery had better results than the PT group. To me, that seems to say that overall surgery had better outcomes. However their conclusion states “PT was noninferior to APM for improving patient-reported knee function over a 24 month follow up period.” Either I am missing something, or their conclusion doesn’t match their results. I think a better conclusion could be that although APM showed slightly better long-term results when compared to PT, PT had comparable short-to-mid-term results and should be the first treatment choice in adults with non-obstructive meniscal tears.

[jeffpeckins]

1. Are HA one of his primary complaints, or are his HA just something that happens occasionally? If this is a primary complaint, I would have asked if he believes the neck pain and HA have a correlation to one another. I would also have looked closely at his upper cervical spine in the objective. Similar to Matt, I would want to know his 24 hr pain pattern for both complaints. If he has increased pain the longer he is at work and sitting, I would use this info for education later on about work ergonomics. Did any of your objective testing reproduce his lateral proximal arm pain? Were you able to reduce his arm pain with scap relocation or assistance test?

2. If most of his symptoms are occurring at work, I agree that postural education would be the first thing I address with him. I would also give him a doorway pec stretch and chin tucks that he can do at work. I would do snags, but have him do so to the L as to not aggravate his symptoms and to open up his R side facets. (Did he have pain with your PIVIMS/PAVIMs to the R?)

3. Again, if his pain increases while he sits at work, I would use this info in my postural education. I would discuss the effects of gravity on the spine in sitting vs standing. I would recommend he take frequent standing breaks or get a standing desk if easily available at his office. I would make ergonomic recommendations about his computer screen height and if necessary alter his seat height when looking into the microscope.

4. Yes I would consider using thrust techniques with this patient. I would try and determine if patient had a preference for this – if he had prior experience with a PT or chiropractor and if they used thrust techniques, if he believes what they did helped or not. It is also something to try that takes very little time to do. I would test-retest and see if it made cervical R SB or extension or right-back quadrant AROM any less painful. If he had less pain after the thrust technique, I would do it in the beginning of every treatment session, at least until his severity and irritability decreases.

[jeffpeckins]

AJ,
First of all, Laura (another PT who works at the clinic) told me that you were using US on that patient and she got a kick out of that!

Similar to what others stated, if the patient specifically requests a modality and believes it will heal her trigger points and tendons, then I think it should be incorporated. I would personally use it for as short of durations as possible, just enough to satisfy her. If you had used US for 30 min and then had her go home afterwards, I believe that would be less-ethically sound decision. But you used the US to gain rapport with the patient and for buy-in to do other more research-backed treatments.

I like what you said about you treating a patient, not a population. That is something that is easy to forget, especially when trying to apply research into practice

Katie,
I am glad I’m not the only one who suffers from all of my patients wanting to see AJ! I like your point about patient values/expectations being as critical in their care as the other two tiers. That is something that is east to lose sight of, especially now as I am focusing more-so on improving with gaining clinical experience and using current literature in my practice.

Matt,
Your scenario is also very interesting, because not only does it effect the patient’s care, but it effects the success of the business. I’m surprised that the physician is so adamant about the patient receiving US. I’m wondering if it would be rude to send him a research article or two to update him on the current evidence. Is it common in your setting to have physicians as involved as that one is in your care and treatment of your patients?

[jeffpeckins]

I had a patient who was seen by Katie for many weeks for posterior knee pain and severely limited flexion ROM. Katie was unable to make many significant gains, so she referred him back to the physician for more diagnostic imaging. Fast-forward about one month, and I am evaluating him for a “quad tendon rupture.” He has absolutely no pain or weakness with knee extension, and all of his pain continues to be in his posterior knee. I was very confused about this, so I called the referring physician and spoke to her. She said that imaging showed a quad tendon rupture, and that he has decreased knee flexion ROM due to “bone on bone arthritis” (side note: she tells ALL of my patients this and it is incredibly frustrating). I told her about how my clinical findings show no evidence of a rupture. The conversation concluded with her telling me I should treat his rupture so that she can give him a shot in his knee to help decrease his posterior knee pain. I ended up seeing him two more times, the first to give him an HEP to improve quad strength and promote quad tendon healing, and the second to make sure his HEP was being followed and he was doing his exercises correctly.

I made the decision that it was unethical for me to treat a patient for a diagnosis that I did not find any evidence for with my objective testing. Yes, an US may have diagnosed him with a rupture, and even if he has one somehow, it is not why the patient is seeking PT treatment. He wants to decrease his posterior knee pain and increase his ROM. I’m not sure if this was the correct decision to make, but I felt uneasy about using his time and money to treat him for something that was not going to help him achieve his goals.

[jeffpeckins]

One thing the article emphasizes that I agree with is the importance of parent participation in the child’s physical therapy. There have been times when I am very impressed with athlete’s parents, because they are able to pick up on their child’s biomechanics and are very in-tune with their child’s pain. They may not know exactly what is going on, but they definitely know when their child is moving differently. When they participate in my PT sessions, they will begin to notice the biomechanic aspect of things I point out to them, and they can do a great job of reminding their child of these things when they are doing their HEP or participating in their sport. As the article mentions, filming the athlete’s movement helps a lot with this. I think kids can be motivated, but they have a difficult time seeing the end-goal or end-result, which makes HEP adherence difficult. Having their parents on board really helps with this. I think making their exercises sports-specific is helpful, but ultimately its tough to hold a young kid accountable for their rehab.

[jeffpeckins]

I agree that kids have a difficult time expressing themselves. Not only are many only able to differentiate pain vs no pain, many of them have no idea what causes their pain. A lot of times I will ask about their aggs and eases, and they have no idea what to say. At this point, I try to give them examples, and many times that helps them. But still many will not know how to answer, because they don’t think like that. So I have found that if I can tell I’m not getting anywhere drilling them with questions about their pain, its much easier and more specific to try and act out their sport or activity they participate in.

I also agree with Casey that making their exercises as sport-specific as possible helps bring in context to their pain. I believe that most athletes are motivated to participate in PT, however making the connection between their deficits and pain, and their ability to perform well is very important. I find that I oftentimes have to be very open with what I am doing and why I am doing it, and how it will help them either have decreased pain, or improved performance.

[jeffpeckins]

1) Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
– Is she able to link the recent worsening of symptoms to a traumatic event or change in usual activity?
If not:
– History of cancer? Increased pain at night that can’t be changed with change in position? Night sweats? Recent unexplained weight loss?
– Any other body regions painful?
– Yellow flags: fear of movement, anxiety, other psychosocial factors?
– Did she think that a specific aspect of previous PT was essential to her pain relief?

2) Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?
– Yes: MOI, decreased cervical flexion strength, point-tenderness/ myofascial TPs
– No: no referred shoulder/UE pain, no dizziness/nausea, HA, etc
– I believe she would be a better fit in the “neck pain with mobility deficits” category.
— Central pain, limitation in neck motion, limited cervical ROM, neck pain at end ranges of AROM (however not PROM…), C and T hypomobility, motor control deficits

3) Do you see any red or yellow flags associated with this condition?
– Yellow: fear avoidance (not wanting to drive), multiple PT treatments, was in cervical collar for 4 weeks, “always has pain”

4) What concerns do you have about the patient’s current presentation and previous treatment?
– Lots of passive treatments, depending on how much exercise she did
– Has she been given an HEP from previous PT, and if so, did she attempt that before she sought out PT again?
– She has never completely resolved her symptoms back to baseline
– Worsening symptoms even through there doesn’t seem to be any recent traumatic incident or reason for the increased pain (i.e, driving more often, longer work days, increase in activity)

5) What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
– 1st: Cervical AROM in non-painful ROM (or minimally painful if non-painful not possible) which will likely be supine
– 2nd: Education and advice regarding the necessity for continued movement and exercise (especially aerobic such as stationary bike)
– As quickly as possible begin including mobility and strengthening exercises, not relying very much on MT and decreasing amount of MT time

6) Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?
– Wouldn’t do Grade-V mobilizations due to osteoporosis status

Additional Discussion:
– I think determining the patient’s thoughts and beliefs about why she is in pain, why the pain keeps coming back, etc would be helpful. She seems to have some yellow flags that are concerning and likely inhibiting her recovery. I would bet that she is hyper-focused on her pain and thinks that something is anatomically wrong with her following the MVA four years ago.
– Research has been shown that education is very helpful in patients suffering from WAD. What education would you provide this patient and how would you reassure her that she will get better? (Side note: this is assuming that we would categorize her in the WAD category, but I’m sure this is helpful regardless of categorization)

[jeffpeckins]

Erik,

I love your phrase: “this will help us map what you can do.” That is a much better way of phrasing it and it allows a negative experience for the patient (pain, inability for patient to do something) into a positive experience where they believe that their discomfort helped you figure out how to appropriately treat them.

Also, I believe you are right. As a new clinician I/we aren’t going to know everything and have all the answers the patient is looking for. However we can control the other factors (patient rapport, timeliness, humor, etc) which will also help patients get better faster.

[jeffpeckins]

In response to AJ’s post, I am very lucky that I work in an environment where I always have one-on-one patient interaction. I never have to worry about balancing multiple patients at once, or worry about patients feeling like they don’t get enough time with me. It is really helpful because the work environment makes it easy for me to develop rapport with patients and to make sure I have addressed all of their questions and concerns. I am sure that I will eventually work in private-practice environments where I will need to learn better time-management skills and balance treating multiple patients at once, all while ensuring they feel like they have adequate attention.

Similar to my response on Dinhu’s article, I can improve in my patient education, and I hope that as I develop more confidence in my skills and knowledge, I will do a better job with this. In the meantime, I will need to make a conscious effort that I am explaining what is going on with the patient, what my treatment approach will be, and why I believe the interventions will help the patient. All while taking the patient’s expectations and opinions into account.

I also should make a bigger effort to show patients that I am being flexible with them and their time with me. For instance, with two patients this week, in order to fit them into my schedule, I put their appt time 15 min earlier than I usually have to work in the morning. I didn’t say anything to them because I didn’t think it mattered. However this article states that patients appreciate flexibility and making them feel like they’re a priority. So in the future, when I make sacrifices or am flexible with patient’s appointment times, I should try and casually make them aware of this, as it may enhance the patient-therapist interaction.

[jeffpeckins]

In response to Dhinu’s post, something I need to improve on is “delivering clear diagnosis, prognosis and explanation of the patient’s problem”. I struggle with this and for several reasons. Sometimes I am not exactly sure what the diagnosis is. AJ and I talk a lot about committing to a diagnosis, so that is something I try to do, but there are times when I am not really sure what is going on. Other times I am confident in my diagnosis, but talking to the patient in terms they can understand is difficult. In an attempt to simplify things and use less technical/scary language, I sometimes find myself over-talking and confusing my patients, something that has been mentioned several times on this thread (I’m glad I’m not the only one!). Another aspect that I need to be more mindful of is taking into account patient’s expectations and previous experiences. I do a good job of finding out and talking about this to patients in the initial evaluation, however it is something that needs to be discussed and tweaked throughout the patient’s time in PT. Their opinions may change, or I may think their opinions have changed when they actually have not. Lastly, something I have never considered is how much older patients and/or LBP patients care about the healthcare setting and organizational aspects of the PT experience. This isn’t something we can change a lot as residents, but it is something to be mindful of.

[jeffpeckins]

One example that comes to mind happened last year while I was a student. I was evaluating a patient with cervical pain who had an MRI done (35ish yo female with no neurological symptoms). In an attempt to get an idea of her interpretation of what her physician told her about the MRI, I asked her what the MRI showed. She listed off about 10 things wrong with her saying things like “slipped disc, degeneration, head too far forward, etc.” Like the article stated, since she was in a lot of pain, she was hyper-focused on the negatives and her interpretation of the findings were “colored by her psychological state”. Before I knew it she was crying and she became very upset.

With the help of my CI, we were able to calm her down a bit. We emphasized that these findings are normal and typical for any person her age, regardless of if pain is present or not. It took several sessions to really get this education through to her, but eventually she demonstrated less fear about her condition and we were able to help her get better. We used the teach-back method often with her after pain education, so that we had an idea of what concepts about her pain were clear and what were not. It also helped us understand which aspects of our education she most connected with.

I liked this article because it pointed out that patients who are in a lot of pain are vulnerable to harmful language and “seek information that supports (their) vulnerabilities.” When I read the educational handout that Ben received, I did not think it was scary or that the language used was threatening. However I wasn’t reading it through the eyes of someone who has been in pain for years, and also has a family member that has been diagnosed with “failed back surgery syndrome.” Thinking about the language I use through my patients’ POV will help me be more conscientious of what words I am choosing to say.

[jeffpeckins]

Erik, in reference to your comment about making a manipulation an event – I think this is the perfect example of being able to use a treatment and frame it in whichever light you choose, taking into account patient-preference. For example, if a patient states previous pain-relief following going to a chiropractor and enjoys having manipulations done, then I would choose to make it a grand event (with exercise following the manipulation of course). However if a patient expresses no strong feelings towards manipulation, but I think it could help them, I may minimize the event and try and work it into other joint mobilization techniques. If a patient expresses fear with manipulation, then I will probably find another technique to utilize. I believe that the important part is determining the patient’s thoughts and beliefs about manipulation (or any treatment) and then altering your approach with its use.

Jon, I’m curious as to how detailed an explanation the research study gave patients about the intervention. Did it use layman’s terms or was it technical? Did the study allow for patients to ask further questions? I ask because sometimes I have trouble finding the line between educating patients and over-educating them. Were the explanations more about how to perform the intervention, or was it about why the intervention would be helpful to them?

I think this article is an important reminder of the importance of every word we say and every non-verbal gesture that we make in our interactions with patients. I think that as a profession, we are so pain-oriented, but I believe this may backfire on us. In my doc system, I can’t submit a note unless I give a numeric pain rating of before and after treatment. If I am constantly asking a chronic pain patient about their pain with every exercise or manual technique I perform, I am reinforcing the idea that it is likely that movement will increase their pain and further damage their body. This is unintentionally providing a nocebo to an already likely anxious and impressionable individual. Chronic pain is oftentimes present in the absence of physiological damage, so framing my interventions in non-threatening ways should hopefully help decrease their fear of pain with movement.

[jeffpeckins]

This article reinforces why I decided to participate in an orthopedic residency.

The SCRIPT tool that the article presents, similar to VOMPTI’s clinical reasoning form, is geared towards an initial evaluation, however can help guide follow-up treatments. Having a systematic approach to an initial evaluation is helpful for numerous reasons. It ensures that all relevant hypotheses are considered, and helps guide the subjective and objective exam to assist in ruling in and out diagnoses. This is something that I can benefit from, as it makes me feel as though I am considering all possibilities while focusing on the most likely ones.

Especially as a new grad and novice clinician, every patient encounter I have is an opportunity for self-reflection and growth. I have limited experience with meta-cognition, or “thinking about your thinking” as the article puts it. Having a mentor ask questions about why I performed a certain objective measure, or why I chose a specific intervention, helps facilitate this idea. With a full year of mentorship, I hope that I begin to think like this on my own and that it becomes more automatic, as well as in the moment (reflection-in-action rather than reflection-on-action). The article states that this is a defining characteristic of an expert clinician. I also feel as though this lays the groundwork for lifelong growth and self-challenge.

Casey, your bull in a china shop analogy is hilariously accurate to how I am feeling as well. Something that this article helped me remember is that a patient’s SINSS is extremely important to understand in order to have good patient outcomes. Every time I have completed an initial evaluation and seen my patient the next visit, they have told me that they were in increased pain and/or soreness afterwards. As this is somewhat expected, I think I have a tendency to be overly-eager and aggressive with my evaluations, in an attempt to collect a ton of information. I do this hoping that the more information I have, the more accurate my diagnosis will be, and I will have more impairments to address. I like that in the case example in the article, the mentee compiled a list of objective asterisks, so that the mentee could provide intervention and know how it affected the patient’s pain. If I can identify an intervention to decrease the patient’s pain (or reduce whatever issue they have), I have a starting point to my treatment, as well as increased patient buy-in.

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