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Would you change anything regarding this search strategy?
1) I think it was a great search strategy, especially if it gave you 3 articles that you could easily skim through and apply to your patient. You kept it simple and found exactly what you were looking for with a high-quality article.
Before reading this article, what were your views regarding SNAGs? After reading this article, has your opinion regarding this technique changed?
2) Prior to reading the article, I utilized SNAGs pretty often with upper cervical patients who had pain/limitations with rotation. I like utilizing them in HEPs on the day of the evaluation to immediately start addressing ROM deficits. After reading the article, I feel much more confident in my reasoning to use them, especially with this population of cervicogenic headache/dizziness.
Have you ever treated cervicogenic dizziness? If so, what techniques or interventions have you found helpful?
3) I have treated a couple of patients with cervicogenic headaches/dizziness. My initial treatment focus was addressing ROM deficits with CPA/UPAs and METs, then I transitioned to deep neck flexor training and proprioception exercises (laser with cervical motions + DNF activities) as ROM increased and pain/dizziness decreased.
1) Given that the systematic review says that there is not evidence to show any benefit for physical therapy with Bell’s Palsy, what treatment choices would you make going forward with this patient?
I feel like education is a big piece for this patient, like everyone else has said. think educating this patient on the pathology and the typical prognosis, as well as how stress can affect her prognosis, will be helpful to improve her understanding of the situation.
2) Is a systematic review the most applicable level of evidence given this pathology?
I think the systematic review isn’t a bad place to start because it gives some basic background information with a pathology that I personally have no experience with, but I think looking at other sources, like RCTs or even case studies may have been helpful for a more specific question.
3) Since there is weak evidence for interventions, what principles or concepts do you think apply from other body regions/practice in general that you would use to guide your treatment and POC?
Again, I think education would be important for her, but then creating a POC and HEP centered around her goals, focusing on the whatever impairments were found, and ensuring that she has a good understanding that this may not be a quick process. I definitely think it’s hard when there isn’t wonderful evidence to support our normal strategies, and it’s even more difficult when it’s something we are less familiar with. I’m really interested to see how this case turns out!
Like everybody else is saying, social media could be a great platform for sharing knowledge, but I feel like it is so bogged down by influencers and companies that are trying to sell techniques or equipment, that it really isn’t even about the information. It’s just another marketing tool, and I think some clinicians may be kind of hoodwinked into buying into this crappy information based on the “evidence” they have to support whatever it is they are hocking.
All that being said, do I still go to some social media pages for ideas for new or different exercises or more creative ways to do some basic activities? Absolutely. But I am more critical of what I’m looking for and deciding if it’s really going to address what my patient needs.
I completely agree with Helen about how social media could change the face of our profession! I think this is an area where PTs have struggled for so long, and now with the evolution of social media, I think we are missing out on opportunities to engage with the public and inform people on what we do and why we can help. I feel like it kind of relates to our Zoom talk the other day with community education for coaches in these youth leagues to help educate parents and prevent injuries down the road for the kiddos. This is an area where I really think we should be thriving and putting ourselves out there, but we’re still not hitting the mark for it. I’m not sure what the answer is to that or how we can change it on a large scale, but I feel like even starting small with our own communities would be better than nothing.
1) I feel like I still struggle with this too. I tend to be more specific at first, then broaden out my terms if I need to, then I tend to skim abstracts until I find something that most closely fits my PICO. I also like to look at the references in some articles to see if they can help guide me towards a better/more relevant option.
2) The exercises are pretty much not functional, but the PNF group did seem to at least progress more towards a functional movement pattern, but again, like Anna and Helen said, there are very few reps performed in a LOT of time, which doesn’t seem like an adequate workload to me.
3) I agree with everyone else on this one. It’s hard to put much stock into a surface measurement of deep muscles that has limited reliability with no real clinical value.
4) Like Anna said, I thought the population was pretty narrow, with a bias towards a younger demographic. It seems like this article took a step back from functional activities and higher-level exercises to investigate the worth of very basic, low level exercises which doesn’t make a lot of sense to me. As to Steve’s point, I think the outcomes may demonstrate the benefits of more active treatment strategies over passive ones, like ultrasound.
Subjective info:
– Alleviating factors or position of comfort?
– Any previous treatments?
– Any other previous wrist injuries/issues?
– Dominant or nondominant hand?
– Any popping/clicking with movement?
– Any numbness or tingling?Objective Info:
– ROM (A/P/R)
– Grip strength in multiple positions
– Special Tests (DRUJ Ballottement, dorsal RU ligament shift test)
– PalpationDifferential List:
– TFCC pathology
– Superficial dorsal radioulnar ligament sprain
– Keinbock’s Disease
– ECU tendinopathyAs far as imaging, I think this patient could benefit from imaging to rule out fractures and more serious pathology, especially with the chronicity of the injury in an active 18-year-old. I agree with Steve’s point, I would feel much more confident in suggesting imaging with a discrepancy between symptoms and objective findings or a gradually worsening pattern for this particular patient.
I’m thinking along the same lines as Helen- what does her other shoulder look like as far as hypermobility? And does she have a history of playing an overhead sport as a kid/younger adult that may have contributed to some instability that is just now getting noticed because of the other issues going on? And as far as using a cluster of tests, especially with SLAP/bicep concerns, I think adding Speed’s or biceps load II could have (maybe?) given some differentiation to the mechanism of the injury, like Anna was saying, because the bump just doesn’t seem like enough of an impact to have done that much damage at the shoulder.
Differentials:
– Impingement
– Musculotaneous nerve entrapment
– RC dysfunction
– C5/6 Radic
– Lateral epicondylalgiaMore questions: also after Taylor’s clarification
– How much impact happened from the “bump”? And did he directly impact the elbow or shoulder?
– Has she seen anyone else for this/had imaging done?
– Any changes in activity leading up to initial injury?
– Is the sharp pain new or has it been present since initial injury?Objective Tests:
– Cervical screen: A/PROM, Spurling’s, compression/distraction
– ULTTs
– Sensation over arm
– Strength testing: shoulder ER/IR, flexion, abduction; elbow flex/ext & sup/pronation; wrist flexors/extensors, grip strength
– Shoulder: Hawkins Kennedy, painful arc, SAT, A/P ROM
– Palpation over lateral elbow, mms of RC1) The “S”’s of treadmill analysis- this is SO HELPFUL. I feel like this gives me a solid framework to systematically evaluate someone’s gait so that I can be more consistent with my assessment and be more confident that I’m making good recommendations based on what I’m seeing.
2) Nerve hydrodissection – what’s actually happening in the tissue and indications for it/what to expect afterwards
3) Really great review of the common nerve entrapments, anatomy review of lower leg and ankle/foot; definitely helps broaden my differential list and potential areas of compressionWhen I was in an outpatient clinic in Houston, I was able to see several post-op RC repairs and I feel like there were some similarities with the protocols, but each surgeon typically had their own, with small differences in ROM limitations or when to start resisted movements, but the basic timeline was similar to what the UVA docs suggest.
I agree with Steven and Anna, we really have to tailor the protocol to the needs of our patient and where they are at post operatively. I feel like I still struggle with how much to accelerate some patients on a protocol to make sure that I’m not stressing the tissues too much, too early in the healing process. I find that I go back and reread the op notes more than anything to figure out why someone may be doing very well or lagging behind. For you guys that don’t use Epic, do y’all have access to op notes/op reports at all with your documentation system?
Taylor/Anna: I feel like it really depends on the patient in front of me. I feel like lately I’ve had a few patients that have a lower educational level, and they’re fixated on their “shattered” or “crushed” discs, so I’m having to educate on more specific structures than I think I typically would. I try to do my best to educate to their level of understanding, but it’s definitely much harder when all they hear from the doctor is crushed or shattered without any other information to decrease the fear associated with the injury. On the other hand, I have a couple of patients who are so hypervigilant and focused on their injury, that I try to stay less specific with my language to reduce their focus on that particular region. Definitely still a work in progress for me though. Do you guys have any strategies that y’all use for those hypervigilant patients to reduce focus on that body part?
1) What do you think about my search strategy? Tips/pointers that you’ve found helpful for other literature searches?
I feel like I still struggle with my search methods too. I think your strategies were pretty thorough, especially with bringing in “costovertebral” and searching other articles’ reference lists. I might have dropped “spine” in the phrases, just to see if that brought in any different results.
2) Read through my summary and the article, then let’s talk about statistics:
– What do you think about their findings in the results section?
The results seem to support STM for improvements in subjective and objective measurements, but I agree with Taylor, the results were hard for me to decipher with all the different points with inter and intra group findings, but I felt like the graphs helped clarify some of the results. I thought the author did a good job of listing limitations and possible biases of the results of the findings as well.
– Did they draw appropriate conclusions based on the statistics?
I think it’s fair to say that the conclusions with improved lateral flexion and percentage of pain were appropriate, but again, I think the conflicting results with inter and intra group differences make the conclusion of this study less valid, especially with the small sample size and other limitations.
– What are your thoughts on statistically significant vs clinically significant?
I feel like this article was much more focused on the statistical significance rather than the clinical significance with regards to treatment, and I would have been interested to see more clinically relevant measures utilized to determine if there was a more functional/clinically relevant change with this technique.3) Any other general opinions on the article?
I thought this article was very hard to follow, and it was hard for me to be able to find any information that I feel like would change my practice/implementation of this technique. I thought some of the inclusion materials for this study were very nonspecific, but I also thought that it was interesting that a researcher was diagnosing the mechanical thoracic pain rather than a blinded clinician.1) Looking at the body chart, what is your main hypothesis and 1-2 differential diagnoses?
• Primary: Mid cervical facet dysfunction
• Differential: myofascial (Suboccipitals, levator scap), upper cervical facet dysfunction2) Now utilizing the subjective information provided, does your primary hypothesis change? If so, what is your primary hypothesis and differentials?
• Primary: WAD with myofascial (upper trap, levator scap) dysfunction
• Differentials: upper/mid cervical facet dysfunction3) After reading the objective findings, is there a specific pattern forming which can help rule in/rule out some of the differentials? Which information seems to lead towards your hypothesis?
• This sounds like there is some muscular involvement and/or motor coordination deficits, but I feel like I need more information to have a better picture of a pattern.4) What else would you have asked in the subjective and/or what other testing would you have performed?
• Subjective: numbness/tingling? imaging after MVA? Medical care after wreck? 24 hour pattern? Previous neck injuries?
• Objective: CPA/UPAs, ULTT, cervical flexion endurance test, aberrant motion with A/P/R?I agree with everybody that this is a hard topic to research effectively. Barrett and Helen, this is something I’ve really been focusing more on this last week too. I’ve been trying to be more consistent at assessing-reassessing after specific interventions, rather than after multiple techniques so that I can assess my ability to achieve the results I want. I feel like I’m in the same position as Anna where I feel like I’m not always sure what functional movements are appropriate to assess-reassess, particularly when the patient has multiple areas of impairments. I also feel like sometimes it takes so much time to assess-treat-reassess when there are multiple areas of impairments. How do you guys manage that with the rest of your treatment without spending all day with your patient?