[Katie Long]

Laura- Good point about the shoulder abduction test, I hadn’t thought of that, but it makes sense. I have been continuing with UPA grade III-IV mobilizations to his upper and mid right sided cervical spine, which I initiated at the eval due to his symptom-free hypomobility. I then progressed my mobilizations to include Evly glides with neurodynamic positioning following his positive response after the eval.

Jen- He was almost finished with his dose pack by the time he got to me, I think he had a day left. By the time he followed up with me, he had completed it. I think a large part of his success with treatment is due to the dose pack aiding with management of any initial inflammatory process that was going on, which enabled me to perform my interventions to treat his impairments with relatively low irritability. The fact that he has had continued success throughout our time together without the dose pack tells me that, while the dose pack may have been helpful in decreasing his irritability, the interventions in PT and his HEP are aiding in his continued improvements.

[Katie Long]

Thanks Sarah! I think I really need to focus on the postural components over the next few visits. His periscapular strength is okay, but his endurance is pretty poor. He gets fatigued easily and I think you’re right, that may be a large part in his current symptoms and a good way to address/prevent any future issues.

[Katie Long]

Hey Tyler,

I agree with having some trouble making sense of his presentation. It seemed very neurodynamically driven and seems like the whole system was a little irritated. I did look at his first rib mobility and it really wasn’t all that remarkable, not tender, not notably stiff and didn’t produce symptoms.

As an update: He came back after the evaluation with reports of no scapular or posterior arm pain, but continued NT in the hand. With ROM testing, he still got mild posterior arm symptoms with extension R quadrant (but no change in hand symptoms). His ULTT and Radial nerve tension testing was negative bilaterally for symptom provocation at full testing position. During Ulnar nerve tension testing on the right, he reported resolution of his R hand NT. We continued R sided cervical UPAs and added Elvy towards the right with the R UE in median nerve tension, then progressed the following session to Elvy away (to the left) with R UE ulnar nerve tension. We also incorporated some pec minor stretching and periscapualar strengthening for improved posture.

[Katie Long]

Hey Justin. Sorry for any confusion.

Yes, ULTT reproduced his arm symptoms with the same quality, although perhaps more intense. However, ULTT did not produce his NT in his hand.

CPAs and UPAs were not painful during any testing, just very stiff.

I did support his UE and re-checked his ROM, which did not alter his symptoms with ROM testing.

Hope this helps!

[Katie Long]

I just saw this, thanks Scott!

[Katie Long]

Eric- Thanks for the library builder. It was an interesting read. I don’t think that I had ever considered that the composition (and potentially the innervation) of these meniscoids would change with age, although that makes sense. It definitely makes me think about the utilization of some traction and mobilization over manipulation to the locally inflamed/symptomatic joint segment to potentially decrease irritability as compared to potentially increasing irritability.

[Katie Long]

Hey Jen, what I meant by this “type” of patient was a patient with history of previous neck pain who now presents with neck pain following a somewhat benign “trauma”. Painful facet opening and closing of apparent mechanical nature. Fear of neck pain returning. No apparent neuro involvement. etc. I feel like I have a handful of these similar patients right now and felt that this journal club would be a good way to get the most bang for my buck in addressing this patient population I seem to be seeing a lot of in the past month.

I like your idea of utilizing the “exercise as medicine” analogy. Luckily, he is already pretty bought in to therapy because of his previous successes, but Ill definitely see if I can work it in.

Justin- I agree with you about the bias regarding patient requests. I often feel the same way and am maybe less inclined to incorporate the intervention (often they want “massage”) unless it really is necessary.

Tyler- I haven’t incorporated SNAGs yet! Ill try that this week.

[Katie Long]

Eric,

Thanks for this post. I am very excited about this series from JOSPT, as I have always had a hard time reading and interpreting literature. It is definitely not my favorite part of being a physical therapist, but I certainly recognize that it is my duty to be an informed consumer of current literature for the optimal care of my patients. I am looking forward to seeing what other segments they produce.

In regards to the discussion of bias, I think confirmation bias is something I am 100% guilty of. I am much more likely to implement an intervention that I have had success with with a previous patient as compared to an intervention that was not successful with a previous patient, regardless of the current patient presentation. I then find myself in a bit of a rut, doing the same things, and have to balloon back out to make sure I am not missing things.

I thought the part on recall bias was interesting and maybe isn’t something I had considered. It made me think about how I may not need to always use the “sexy” techniques with patients, often times the basic, impairment based interventions (and therex**) are what patients need most, and that should not be overlooked.

[Katie Long]

Wow Tyler, interesting case.

1) I think given the rib and scalene findings with neurogenic sx, I would have TOS on my differentials. I also would have some sort of peripheral nerve entrapment or double crush on my differentials.

2) Regarding her irritability, I think a lot of my evaluation would have been spent getting a few key objective findings, as you did, but then trying to find ways for her to relieve her symptoms. I wonder if you have tried some of the neurodynamic positioning that Kristin talked about? I wonder if she would be better able to tolerated a supine position with elevated LE or tensioned contralateral UE with her affected UE slackened?

3) I wonder about trying some MWM UPAs on the CT junction in sitting with her rotating towards the right (or left)? Seeing if that changes her numbness? Did you assess cervical ROM with UT slackened?

4) I think this depends on the patient and how much they buy into what you’re trying to sell them. I have had patients that are completely down with trying anything and I tend to push them a bit more to see what we can change in regards to their symptoms. But I also have patients that are very cautious and are not completely sold, so I don’t tend to push them quite as much. But this is hard, and something I am still struggling with. What does your patient think about what is going on? What did you “sell” her? and does she buy it?

Good luck! Keep us posted!

[Katie Long]

I agree with Tyler in relationship to Tim Uhl’s presentation on RTC exercise prescription. I always find articles like this helpful in laying out exercises in regards to load for potential progression/regression. I often find that I have an end goal, but sometimes have a hard time filling in the gap between that end goal and the current patient presentation.
I also thought the segment on running vs. U-HR was very interesting. The point they make that it takes 482 unilateral heel raises to mimic the overall impulse of the achilles tendon during a 30 minute run was very interesting. I thought that was a surprising connection/comparison, although it makes sense when you think about it. It really made me think about exercise prescription in this patient population, who are often runners.
I do wonder about applicability of this study to my patient population. These patients were young (mean age 22.1 +/- 1.8 years) and it made me question the generalizability to those with more degenerative tendinopathy as compared to those who are younger with over-use tendinopathies. I don’t know that there is a difference, but it made me consider how this may be applied to my older patients.

[Katie Long]

Hey Sarah

1) Similarly to what Tyler said regarding differentials, I would agree that I would be concerned about a BSI or posterior tib dysfunction. I also had a similar patient (young athlete) who had “bilateral compartment syndrome” who ended up having some neurogenic components due to a spondy, but it sounds like she is not experiencing any numbness like my patient did.

2) I also think the PMH of her ankle sprains are significant, as her sx seem to be worse on her R vs L, and her R ankle was her most recently sprained. Her talar hypomobility may also be significant in regards to CAI. I am wondering if potential proprioceptive ankle impairments are a contributing factor to her sx during running.

3) I am curious to see what her neurodynamics look like, specifically when tested with a tibial or perineal nerve bias. I am also curious to see what she looks like when running. I am willing to bet she has some motor control impairments and I would like to see if I could provoke her sx when running, as they seem to come on relatively quickly, to see what you can do to change her sx.

4) It sounds like posterior tib endurance strengthening could be beneficial for her, especially if this is a motor control problem. It also sounds like she may be a good candidate for some of the exercises from the running course (toe dissociation/Toga, rearfoot on forefoot stability, SL stance with arch, etc.). Exercises incorporating motor control and stability of proximal and distal components in SL stance are likely going to be very beneficial for her.

5) Unfortunately, I don’t have a ton of experience with these patients, so I don’t know that I have much advice for you from personal experience.

[Katie Long]

Here are the other 2.

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[Katie Long]

Hey Jen, not exactly the same, but I had a patient who presented with peripheral sensitization following a Staph infection in his hand. He presented with fear and apprehension regarding return to bowling and playing with his granddaughter because of his symptoms. He was very confused about his symptoms and why they were so inconsistent, he also seemed to not be able to pinpoint specific aggs. We worked a lot on gradually introducing AROM/AAROM/PROM motion to the system. Elvy cervical glides in neruodynamic positioning was very effective for him, maybe these could be helpful for your patient? A lot of our focus was introducing ROM and neurodynamic mobility without re-irritating the system. It helped him a lot with confidence and fear as well to see how he was able to do something that he couldn’t do a previous week because of his symptoms.

I’m attaching some articles that I found helpful in this case.

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[Katie Long]

Justin,
I loved the RPE for exercises too! I use that all the time with my patients, although I usually just ask “is this easy, medium or hard?” and go from there. I think I should be better about asking how the session as a whole was though instead of individual exercises.

[Katie Long]

Hey Justin,

So I decided to needle his adductors because at his initial visit, palpation to the adductors reproduced his groin and testicular pain. The adductors can also refer into the groin. I was also hoping to utilize the needling to reduce tone of the adductors and therefore reduce tension/pull on the inguinal canal and pubic symphysis. It has been a very successful intervention for him so far.

We have moved on to addressing his rectus abdominus (which also refers to his testicles with palpation) and his obliques with STM (in addition to his adductors and lumbar spine impairments). He has been able to perform functional activities such as back squatting, bench pressing, hip thrusters and cable workouts in the gym following manual tx with no reproduction of his sx!!

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