[lacarroll]

This article does an excellent job of pointing out some flaws in our reasoning when it comes to SIJ dysfunction. I agree with Helen that it seems completely counterintuitive for us to mobilize a joint that has minimal motion to begin with and it seems pointless to mobilize here at all since we are so inaccurate with our detection of the movement.

I really liked how the authors discussed the pathoanatomical explanations and labels, and how that can influence the patient’s outlook and avoidance of activities. I know I still struggle some days with my explanations to patients about the cause of the problem, but I think that explaining how the SIJ/spine is more sensitive to that input will be helpful without using the more harmful words. I think that educating on this sensitivity, rather than “upslip/torsion/whatever” after Google or other healthcare professionals, will help us get these patients back into normal activities sooner rather than later and get them less focused on their pain as well. I think this framework will definitely help me be less clumsy with my words and help the patient get a better, less fear inducing idea of what’s going on.

[lacarroll]

These are some great questions/points!

Helen: We aren’t very sure how long it’s been there, she just recently had imaging (12/19/2019), but it is a smaller lesion (5 x 4 x 12 mm) with no cortical breakthrough or increased bone marrow signal on the imaging. As far as the official stage, there is no mention of that in the imaging report. As far as aggravating factors, running > erging > biking. So all three were aggravating, but running and plyometric activities were the most aggravating. With erging, I don’t think she was very certain about the part that was painful, so that didn’t help much, but I also didn’t do a good job of clarifying. I did test resisted/passive ankle motions, but none of them reproduced her symptoms which was a little weird. I did not test SLR with the tibial bias, but that’s a good idea.

Brandon: Symptoms were worse with/after activities, not really time specific. Her symptoms would typically resolve after resting or by the next morning when we saw her. And again, I’m not 100% sure about the staging and where she fell based on my limited knowledge. Imaging was taken after 6 weeks immobilization. No previous injuries/imaging prior to this incident. Pain has always been over medial aspect of lower leg.

Anna: No real change in activity other than she was in the middle of her season when the pain started, and we were seeing her after the end of the season. She couldn’t really pinpoint any changes in activity leading up to the onset of pain. She was aware of the lesion, but was very concerned that she was still having pain in the area and was more concerned about making it worse with returning to her normal activities. As far as the boot, we weren’t really sure why that seemed to increase symptoms honestly. Have any good thoughts on that? She was interesting because I only saw her for the evaluation. We educated her on a return to activity progression, but we also put a rearfoot wedge in her L shoe which immediately helped her foot posture. As far as therex, we did some foot intrinsic strengthening and SL balance/strengthening activities for her to progress to since she would only have the 1 visit.

[lacarroll]

So I know Anna and I came in late and we may have missed this, but what caused the guy to come back in after a traumatic dislocation 10 years ago? Was there a more recent mechanism that irritated him or new job or whatever it may have been that made him seek out medical treatment now vs 10 years ago?

[lacarroll]

1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?
– Primary: labral pathology
– DiffDx: secondary impingement, rotator cuff pathology

2) Are there any objective tests you feel would provide a clearer picture of this case?
– Sulcus sign, pivot shift, shoulder adduction, GH mobility, scap mobility

3) Do the objective findings fit a clinical pattern? If so, of what?
– Seems to fit with shoulder instability secondary to labral pathology

4) What impairment or limitation would you want to address first with this patient?
– Activation of cuff musculature and closed chain scap girdle stability.

[lacarroll]

1) Looking ONLY at the body chart, what is your primary hypothesis?
L3/4 Lumbar Radic

2) Looking at the body chart AND subjective exam, now what is your primary hypothesis? Next 2-3 differentials?
Primary: Hip OA
Diff dx: labral tear, lumbar radic

3) What are some other questions you could have asked to help rule in/rule out your hypotheses?
– Difficulty with putting on/taking off shoes?
– Painful clicking/popping in her hip since incident?
– Pain with bending, twisting?
– Did she receive any medical treatment after the misstep 2 years ago?
– Did she quit her previous exercise regimen? If so, why?

4) Does the objective information/patient presentation make you think of a particular diagnosis?
This presentation makes me think hip OA with the pattern of pain that’s worse in the morning, less pain with activity, limited ROM (esp. IR), increased pain with weight bearing, pain with squatting, age >50.

5) What would be your first thought on treatment for this patient?
Educating patient on prognosis and importance of activity; inferior/lateral hip mobs to improve joint mobility

[lacarroll]

I agree with y’all that this study was incredibly well done according to the PEDro scale. They very clearly outlined the inclusion/exclusion criteria, the concealed allocation, blinded subjects and assessors, multiple key outcomes, and between-group statistical comparisons.

As far as clinical applicability, I don’t think this article will dramatically change the way I treat patients with hip OA, but I think it’s a great reminder to include components other than manual therapy and exercise into the plan of care. Like Taylor and Steve were saying, this population may need a lot more education in general about the disease process, prognosis, and activity guidelines to improve their baseline. And I agree with Anna that we still have skills and services to offer these patients, especially since there was an improvement in pain and function in both of the groups in the RCT.

Staying on the clinical applicability of this article, I thought the exclusion criteria was super limiting for this study compared to patients that we see walking into the clinic. I understand that they were ruling out comorbidities and reducing the margin of error, but the patients included in the RCT were patients that did not participate in 30+ minutes of walking, “structured” exercise >1x/week, and had been hurting more than 3 months, among others. I’m curious if these outcomes are still applicable with patients who are more active and more similar to patients that we see clinically. Anybody got any thoughts on that?

[lacarroll]

1) Reading only the subjective examination please list your primary hypothesis as well as your top 3 differentials
– Primary: L3/4 Radiculopathy; other top 3: L3/4 Facet, Hip pathology, myofascial strain

2) Does the objective information follow a familiar pattern? If so, what are your primary *’s? If not, what information is inconsistent?
– Seems to follow lumbar radic pattern: symptoms down the leg, weakness, paresthesias, decreased reflexes along L3/4 pattern; I would think that SLR would have been positive

3) What other objective tests would you have performed with this individual?
– Slump, prone knee bend, swing test

4) Given the patient’s current presentation, what is the role of physical therapy in this case?
– I think that there are areas that can be improved, especially since he has such a long history of back pain. He has functional goals like stairs and getting back to his yard work, so I think that this is an opportunity for us to come in and be able to educate and teach this man to move more efficiently in order to prevent flare ups in the future.

[lacarroll]

I agree with Helen, the slinky video is pretty cool. I think these videos reiterate a lot of the things Eric and I discuss in our session debriefs, especially the part about how education isn’t just reading something from the book and then bam it’s in your brain. We have talked so much about how associating a specific patient and what their presentation looks like/sounds like will help me to really cement that diagnosis presentation in my head and help me improve with recognizing the patterns with different conditions. I also like how the slinky guy talks about how the student-teacher relationship is as important in the learning process as the student-student relationship. I feel like having Eric there to push me and make me think about things in a different light is just as important as me having Anna there to ask my dumb questions to and just bounce ideas off of in general.

Like Barrett and Helen said, I think going into an eval with a prediction makes a world of difference. I feel like having that prediction gives me a better starting point to organize my thoughts and guides my line of questions better, although this is definitely still a work in progress for me.

[lacarroll]

Questions:
1) Is there any more information you would have gathered during the subjective? Are there any other outcome measures you would have administered?
– I was curious if she sought out medical treatment immediately after the wreck and if she was the driver or a passenger, but other than that I think you did a great job of collecting a lot of good info.

2) Based on body diagram and subjective exam is there anything else on your differential list? Is there anything you would change on mine?
– Not really. I agree with WAD as number 1 for the differential, but I’m curious what made you put cervical & discogenic lower on your list than impingement and some of the myofascial components.

3) Considering irritability would you have changed your objective exam? What would you have done differently?
– I definitely think I would have been pretty conservative with the objective exam on day 1 if she was super irritable. Did she mention how long it takes for her symptoms to decrease at initial eval or did I just miss that somewhere? Also, how much of the objective did you get done on initial visit versus first day of treatment?

4) What is/are your primary hypothesis or hypotheses?
– I’m sticking the WAD with the mechanism and host of shoulder girdle and cervical impairments that seem to be going on with this patient.

5) What would your PICO question be for this patient?
– In patients with WAD, does manual therapy decrease recovery time?

[lacarroll]

Working hypothesis and differential diagnosis:
a.) What is your working hypothesis regarding this patient?
– Labral pathology with resultant GH instability
b.) What are your next 2-3 differentials? (Ranking order)
– Secondary impingement
– Mid-lower cervical facet
– RTC tendinopathy/partial thickness tear

Special testing:
a.) What are your thoughts regarding the special testing chosen for this patient?
– I feel like the special tests were a little scattered, but I think the ones chosen definitely helped rule out different systems.
b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?
– I think that a few more labral tests could have been utilized just to have more information on the integrity of the structure and maybe see if there is any biceps involvement there as well.

Clinical Pattern:
a.) Does this patient’s presentation fit a clinical pattern?
– I definitely feel like this isn’t a very clean-cut case. There seems to some shoulder stuff going on with some neck stuff, especially with one complaint being more chronic and one being more acute.
b.) Briefly, what are your thoughts regarding his headache?
– I think it’s worth asking him more about onset and frequency, especially with reproduction of it during the cervical screen.

Evolution of Patient’s Symptoms:
a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.
– I think it’s a pretty normal progression, especially for a younger guy with a manual labor type job. He probably thought it would get better eventually until something else happened and it got noticeably worse.
b.) Are there any red flags?
– Not that I can think of

Treatment
What Manual therapy and HEP would you give the patient on the first day?
– Manual: STM to periscapular area, scapular mobs with movement
– Prone Ys, Ts, rows; seated no monies with band

[lacarroll]

I think this questionnaire uses plain, but descriptive language to frame the patient’s perspective of their pain and of their thinking about their pain. I think that the use of the positive/negative metacognitions is a great way for us to be more aware of where that patient is on the spectrum of awareness and mindfulness of their pain and how that can help us treat the patient more effectively. I agree with Helen that identifying and addressing unhelpful metacognitions sounds like a great place to start, but I’m also not quite sure what that looks like in the clinic, other than pain science education.

I feel like I currently have a few patients that demonstrate the “hypervigilance” and “cognitive intrusion” regarding their pain, and I think that my words aren’t quite to the crash and burn level, but they aren’t super wonderful yet either. It’s like Anna said, I feel like I am constantly trying to think of new phrases to use or how I can word things differently to make the patient get a better picture of what I’m trying (sometimes successfully) to convey.

[lacarroll]

I’m not the biggest podcast or social media person, but I’m definitely going to take the time to look some of these up. I’ve listened to a couple of the #AskMikeReinoldShow podcasts and thought he had some great nuggets to share. I follow the [P]Rehab Guys on Insta and reference some of their posts for exercise progressions/regressions for different things. They do a pretty solid job of giving different words or cues to help improve technique and form. They started a podcast earlier in the year too, so that might be another good one to check out, just for something a little different.

[lacarroll]

I agree with Anna that this article was a great review of the anatomy of the forearm and entrapment sites of the median nerve. I thought the author did a great job of narrowing down the differential list and then utilizing diagnostic tests to systematically rule out entrapment sites of the median nerve.

I liked how the article really broke down the author’s thought process of the treatment approach as well as the differential process. I like how the author discussed the pros and cons associated with some of the manual soft tissue techniques that may have been less helpful immediately, but more beneficial in the long run, and I feel like I catch myself in that same circle sometimes with some of my patients. Definitely a great resource for a less common diagnosis and how to approach it in a more direct fashion.

[lacarroll]

Anna: that’s how I understand the hyper/hypo mobile C curve to work too. With her Cspine, I did cervical APR and axial compression, but I think I should have done Spurling’s as well to maximally stress those tissues and feel more confident that they aren’t involved. As far as quantifying her ROM, I used her teeth as landmarks for measuring deviation, 2-3 knuckle method for mouth opening, and her protrusion was to the line of her upper teeth, so that was harder to measure because it was such little motion. As far as test/treat/reassess after joint mobilization, I have looked at the quality of her mouth opening (decrease in C curve) as well as pure ROM for mouth opening, which is showing improvement so that’s pretty cool to see within session.

[lacarroll]

Sorry it took me awhile to get these answered, it’s been a long couple of days, so I’m going to do my best to go down the list and clear up all the questions/thoughts. Here goes:
– Taylor: I definitely thought she fit into the disk displacement with reduction category WITH myogenic involvement. I did not assess joint glides day 1, just because I wasn’t sure me sticking my hand in her mouth to move stuff around was the best idea.
– Helen: so this girl was great in telling me in the subjective that she no longer chews gum, has switched to a soft food diet, and noticed that her headaches tend to come on when she’s been clenching more throughout the day, so that helped me a lot in the decision between cervical vs TMD. I did not do the compression test, but that’s something I definitely want to take a closer look at in future cases. As far as irritability, she was having a really good day when she came in for the eval, so she was pretty low irritability with minimal symptoms. She has SO MUCH muscle involvement that I’ve actually considered dry needling for her. Do you have any good articles supporting dry needling in this area??
– Steven: her psychosocial components were high on my list for the eval. I asked her about her depression and it’s currently under control, but there was a point in time where she took 1-2 years off in college because of stress and depression, so it’s definitely on my radar for this one. I talked with her a lot about her day to day activities and asked her to tell me about some of her stress management techniques and that made me feel better that she had a solid grip on it, along with taking a prescription medication.
– Brandon: I was actually surprised her cervical spine didn’t seem to be involved, but I didn’t do PPIVMs/PAIVMs during the eval. The limitations I found were active with ROM at the TMJ, and again, I didn’t do more accessory testing than that. I chose cervical isometrics for posture because hers is just so bad. I also kind of picked through the Rocabado’s and Kraus’ and mixed and matched techniques for this patient. I had her perform the cervical isos and scap retraction exercises with the tongue on roof of mouth position (TROM), isometric lateral deviations & mouth opening also with TROM, and she fatigued out with these really quickly. And I’ll definitely look into the self-mobs for the HEP, I think that would be a good addition to the treatments in the clinic.

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