[Justin Pretlow]

Thanks Jen,
I think I’ve gotten a little better at addressing patient concerns about imaging findings since the Gail Deyle course. In hindsight, I think I was more alarmed that he’d had an MRI already and multiple injections, so I wanted to make sure I didn’t play into any unnecessary fear or anxiety about imaging findings.

This patient has been tolerating progression of exercises fairly well while reporting decreased symptoms with ADL’s. So I do think the injection has allowed a window of facilitating more movement with less pain.

I could picture this patient when Jake was demonstrating the manual techniques thrown in with the sidelying shoulder sweep. I’ve added in mobility and stretching to the patient’s HEP, and I think using some of the manual techniques to facilitate that motion will be a helpful piece to add.

Thanks

[Justin Pretlow]

Thanks for the SLAP tear/imaging article, Tyler. That will come in handy for explaining lack of correlation between imaging and symptoms.

I haven’t assessed his thoracic mobility, but I have added some trunk rotation warm-up and lower trunk rotation stretching. His left side appears tighter with LTR. I will take a closer look at thoracic mobility next time. It makes sense that left rotational thoracic limitation could increase the stress to the shoulder at the top of the backswing.

[Justin Pretlow]

I was trying to be brief and not list too many findings, but I think I was too brief. I see what you mean that those asterisk signs do not point to that hypothesis.

My findings from the initial eval did not fit a clear clinical pattern, and left me somewhat confused about the diagnosis. I classified it as impingement based on pain at endrange flexion, description of MOI, medial to inferomedial scapular winging and fatigue with scapular endurance test at wall, and lack of a clear clinical pattern pointing to a more specific diagnosis.

After the 2nd weekend VOMPTI course, and reviewing some of the slides, I thought it made more sense to call this secondary impingement, based on his age, scapular winging/fatigue, and training error/overuse contributing to onset.

At second and third visit, Scapular Assist Testing has provided a decrease in pain symptoms at endrange flexion and scaption. Scapular upward rotation at the wall was pain free at times and symptom provoking at times, making me consider scapular dysfunction as having a role.

[Justin Pretlow]

Some of these pearls listed were main points and some were side notes that I found interesting. Please feel free to correct me if I misrepresent a point.

2 simple questions to consider before suggesting imaging:
-Is it in the patient’s best interest?
-Will it guide treatment?

30% Rule – X-rays are not sensitive to early changes in bone

“1 view is no view” – an A/P radiograph can look normal while the lateral view may show an obvious fracture, or vice versa.

Multiple Myeloma is a “cold” process vs. “hot” so it may not show up on a bone scan.

CT scans: Each time an organ is scanned, that organ’s lifetime risk of cancer doubles.

Femoral neck stress fractures: more likely to displace if on the tensile side of the neck vs. the compressive side.

If a scaphoid fracture is suspected, early MRI may be appropriate as x-rays 4 weeks after injury still miss scaphoid fx’s 40-50% of the time.

[Justin Pretlow]

I think the results of this study are applicable to your specific patient. Similar to what Katie and Tyler said, manipulation of a certain segment is likely to have some effect on adjacent levels of the spine. The avg. age of 35, 4 plus years of headaches, and the frequency of HA are all similar to your patient.
Regarding your second question, I think unilateral symptoms can often be attributed to movement dysfunction of the contralateral side or both sides. This would give me reason to consider performing mobs or manipulation to both sides, depending on the specific patient.
I’m not sure how to answer question 3.
Per question 4, one possible mechanism could be a positive psychological effect regarding the expectations of the treatment. Perhaps patients who received a manipulation and heard that gratifying pop felt like they were receiving a treatment that was fixing their problem. And the idea of receiving a passive treatment and not having to work at it between visits could help frame the treatment in a positive light.

[Justin Pretlow]

Thanks Aaron,
That’s definitely helpful. Eric gave me a couple of articles to solidify my understanding of the anatomy. The treatment suggestions in part 2 above look really helpful at a glance.

To the residents- If anyone has access to the article url below, could you forward me the pdf? Thanks

http://www.mskscienceandpractice.com/article/S1356-689X(10)00038-X/fulltext

[Justin Pretlow]

I do think this study applies to the US population. It wouldn’t surprise me if the same study design conducted in the US came up with similar statistics in terms of the percentage of patient prescribed medication and not necessarily being referred to PT before a spinal surgeon. I think we probably need to improve how we sell or market our skill set if we want to become the first choice in treating low back pain. Forming relationships with primary care doctors and making them aware of the research, or demonstrating positive outcomes with specific patients whom they refer is one possible way of helping to make physical therapy their go to instead of referring to a surgeon.

[Justin Pretlow]

Everyone has made good points regarding the article.

My thoughts while reading: I’d like to improve my consistency with empowering patients through education. I may do this well at times, but too easily take on more of the responsibility(or feel the responsibility) when they have a setback or experience some challenges over the course of therapy.
I’d like to do a better job with how I explain a concept or give instructions to patients. I tend to get too wordy and over explain.
Lastly, I’d like to manage my time more efficiently during a session so that I can take a couple of minutes for reflection. Whereas, I typically don’t have time to reflect on a situation until the end of the day.

[Justin Pretlow]

Tyler and Katie-
I completely agree with your points of how the CRF should help with organizing one’s thoughts and prioritizing examination and treatment. I would agree that stepping aside to discuss sections of the eval with my CI in real time was extremely beneficial during clinical rotations.

I like the way the authors describe the SCRIPT form as a way for residents to “show their math” and make their thinking explicit. I imagine this is how the CRF form will help me/force me to grow as a clinician. So much of my thought process during an eval has become automatic. I suspect that showing the math behind my decisions in a clear and organized fashion on paper will be challenging at times. The discussion that comes with filling out the CRF will hopefully improve my decision making and the ability to articulate those decisions.

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