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Kyle FeldmanModerator
We only heard from Steven and Anna but I will still tell you what happened.
She was sent to the ER for concerns of cauda equina. Imaging was negative and she was sent home with a self catheter. Due to the lack of answers she was sent to Reston for further work up.
Imaging showed no cauda equina but did show an unexplained mass.
She was seen by her oncologist and a metastasis of her colon cancer from 2014 was found along her sacrum.She is currently being treated for the cancer and pain reduction with PT
Kyle FeldmanModeratoryour right Steven
During this visit I had a spine specialist and neurologist on the phone. They could not believe the OBGYN situation either.
Kyle FeldmanModeratorSteven
you are correctI tend to use communication with the pediatrician and err on the side of caution and get an image.
There is sadly a lot of data showing missed fx’s from x-rays in PEDS.
So if they do not improve an MRI may be warranted.
I just had a 3 year old the other week with a negative x-ray and there are concerns of a fracture. An MRI is being scheduled in the next month or so if PT does not improve symptoms.Kyle FeldmanModeratorGreat points
You may come across this in the future.
Work alongside parents, coaches, school counselor, anyone to help get her back on track.Kyle FeldmanModeratorgreat points
what guidelines could you use to help determine if an x-ray should be prerformed?
Does age, pain, ROM factor into this decision?Also, would you contact any other providers in this case?
Kyle FeldmanModeratorI would recommend listening to the JOSPT insights podcast episode 1 with Dr Lynn Snyder-Mackler.
She hits on this and other myths in the ACL rehab world.The ACL rehab concepts are really changing. Hopefully the re-injury rate reduces with this change!
Kyle FeldmanModeratorGreat questions Anna and Taylor
I used the Bringham and Womans return to running program from Harvard (attached below)
I also like this other article about runners and bone stress.The patient presented like a combination of athletic pubalgia and a stress fracture of the femoral neck due to WB and load severity, but also the positive tests for atheletic publaglia.
Looking back, it makes sense that both were positive because there was a fracture in a load bearing aspect of the pelvis and the adductors attach to where the fracture was present.
With the anorexia, I was very clear on the importance of the triad in the initial evaluation and she was very open. She opened up about what her issues were and I addressed her need to load with nutrients and 5-6 small meals a day during recovery.
Attachments:
You must be logged in to view attached files.Kyle FeldmanModeratorHere was the result of this case:
Computed tomography identified a non-displaced transverse fracture of the midportion of the right inferior pubic ramus.Conservative management continued over the next 8 weeks, emphasizing pain-free ROM and progressive weight-bearing exercise with running return at 12 weeks.
Attached are the images.
Attachments:
You must be logged in to view attached files.Kyle FeldmanModeratorI think that is a great script for communication. You are not telling the doc what to do, but instead providing your clinical judgement and a recommendation.
As far as medications, I would reference your pharmacology notes from PT school for some of the top meds used.
Each system has a handful for the most common meds used and it is always good to refresh on them.
I would also review the meds of each patient on evals and write down the ones you are not familiar with to help with retention.Kyle FeldmanModeratorGreat reflection Anna and Steven
Its easy to keep our differentials MSK only.
When you cast that wide net you avoid missing sometimes fatal errors in judgement.
contacting the PCP is a great idea.
How would you word that conversation?Kyle FeldmanModeratorGreat reflection Anna and Steven
Its easy to keep our differentials MSK only.
When you cast that wide net you avoid missing sometimes fatal errors in judgement.
contacting the PCP is a great idea.
How would you word that conversation?Kyle FeldmanModeratorI had a patient come for her 3rd visit who has been experiencing 10 years of chronic pain.
We had the typical talks, manual, and graded exposure to exercise and improvements were being made.When she arrived for this session she was rushing, flustered, all over the place, and panicking. Her pain was back up to a 5/10 so I decided to take a new route.
I shut the lights off, had her lay down and we just did meditation and deep breathing. She did it for 5 minutes and after that I said lets start over. She walked out of the door and entered the clinic again.
She had a completely different mood, affect, and presentation.Her pain was a 2/10 now and we ended the session painfree, sweating, and fully exercise based.
She expressed her realization of stress effects on pain and I plan to use this intervention for other patients who come in like this in the future.
Has anyone else ever tried strategies like this?
Kyle FeldmanModeratorGreat discussion everyone.
I like how you focused on listening above throwing pain science out first.
Linking the stress, using analogies are great ideas.
The point I was trying to make about clicking is related to the hypomobility at end ranges vs motor control midway through the motion. If the diagnosis is off, you make be strengthening when the joint needs more mobility or mobilizing when motor control should be the focus.
Differential diagnosis is important and making sure you have a few for TMJ is important because it is not always the disc driving symptoms.
Kyle FeldmanModeratorGreat points Anna
When someone has high pain levels, changes in ADLS due to psychosocial factors, do you find that pain education goes smooth?
How have you changed your education with these patients?
If the patient said the clicking was early in the opening vs end range would that change your treatment approach clinically?
Kyle FeldmanModeratorGreat points
Taylor you seem to have the most experience.
Have you seen anyone with hand pathology get local injections?I ended up sending her to ortho for one directed at the EPL tendon and within 2 hours she was painfree and we were able to do all exercises next visit.
What concerns would you have with local injections near tendons?
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