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I believe the chart that Dr. Boissannault provided is super helpful in assisting us as clinicians to organize some common red flag pathologies that we may come across in the clinic. My biggest take away from his presentation was that red flag symptoms need to be clustered much like we would with any other orthopaedic examination; of course with certain questions carrying more weight than others. With the direct access growing in the Physical Therapy profession it is imperative for us to be able to recognize when patients symptoms are not mechanical in nature and/or outside our scope of practice requiring referral to other medical professionals. Even if my patient does not fall into category I red flags, I am constantly clearing category II or III red flags before performing other objective orthopaedic tests.
I have a patient earlier today who was s/p MVA ~1 month ago with complaints of neck and low back pain. I happened to be the first medical professional she had seen after the accident and immediately my red flag radar was elevated. Even though her main complaint was low back pain my first line of questioning mainly pertained to her neck and head symptoms and the mechanism of the MVA. Luckily for this patient she was negative for upper cervical ligamentous tests and denied any signs or symptoms of underlying concussion or potential fracture. After those were clear I felt more comfortable addressing her main complaints of low back pain.
Jeff to your point about being over cautious with our patients is not a bad trait. I definitely am along the line of thinking better to be over safe than sorry, even if the incidence of true red flag pathologies presenting to the clinic are relatively small.
Erik I think you make a great point about determining the patients beliefs and why they think they’re in pain and using that as critical information that you can utilize to hopefully chip away at those negative thoughts and turn them into positives. Unfortunately sometimes we do not have the patients who come in and say I hurt for these reasons, instead they say something along the lines of “everything hurts and I don’t know why” and they’re obviously there for us to fix them. As mentioned in Journal club pointing out disparities in their complaints and how they are actually functioning in front of us would be a great place to start with some of those patients.
I recently discharged a 50y/o female who was involved in an MVA 4/8/18. She had been seen by another therapist at my clinic fairly consistently for about 5 months for concussion symptoms as well as neck and low back pain until I started seeing her. At this point to my knowledge their treatment consisted of concussion rehab, dry needling, and manual therapy to her neck and back with min-mod improvements.
She had been out of PT for about a month prior to our evaluation together at the end of October and she presented with complaints of constant neck and back symptoms. Similar to the case presented in journal club she did demonstrate what appeared to be mechanical symptoms that I felt could be treated with manual therapy, exercise, and education. I believe this is where I made my first mistake, I did not properly identify the potential yellow flags associated with this case including the duration of time she had been in PT prior w/ complaints of similar symptoms and the fact that her therapy was being covered as part of her settlement following the MVA. Being a new clinician I figured I could fix all her problems with my hands on treatment – (mistake number 2.) We did a combination of mobilizations and manipulations to her C/S and T/S with good short term improvements. She appeared to be getting better but would come in subsequent visits expressing that she felt the same noting no sustainable change long-term. She kept reporting that she felt that her body was 80 and was letting her down and she could not do what she wanted to do on a day-to-day basis. This went on for about 6 weeks before I realized there needed to be a shift in POC.
In early January, I spent a large majority of the session educating her on pain science. I explained to her that the tissues impacted during her MVA have all but healed by this point and her system was most likely in a repetitive hypersensitive state in patient friendly terms (alarm system on high alert and a leaf blowing across sets if off). She appeared encouraged by the shift in POC as I encouraged progressive increase in cardiovascular exercise and a completely hands off approach to care. Subsequent visits she performed a circuit of cardiovascular exercises centered around a treadmill walk (one of her goals), total gym for time, and bike riding. During these visits I did not perform formal pain science education instead pointed out what she was able to do pain free and continue to encourage her participation in her desired activities. We recently discharged her at the beginning of the month, but I definitely feel that I could do it over I would have handled this situation at lot differently now being more aware of the yellow flags that were present during initial evaluation and incorporating more biopsychosocial treatment earlier on in treatment.
Hey Erik, very interesting case.
1. Based on the subjective information presented above what are your top three differential diagnoses? (ranking order)
• CRPS
• Lumbar radiculopathy
• PCL/MCL injury2. Based on the objective information presented above what is your top clinical diagnosis and why? Does it follow a clinical pattern?
• Lumbar radiculopathy (myotomal weakness, dermatomal sensory loss, +slump, +POE, +radicular sx w/ shear testing, familiar pain w/ L/S AROM)3. Is there any information you would have asked during the subjective examination or collected during the objective examination?
• What type of surgery is she planning on undergoing?
• Any other imaging performed for knee symptoms?
• Has she been out of work since accident? Or during recent flare up?
• Functional LE tests (DL/SL squat, SLS)
• Edema measurements?
• Color of LE4. Rank by % her origin of pain: central, nociceptive, neuropathic
• Nociceptive: 60%
• Neuropathic: 30%
• Central: 10%5. Rank which of these you would want to provide during IE: Education, manual, exercise. Why?
1. Education
2. Exercise
3. Manual
• I would educate the patient on objective findings and POC. I would echo the doctor’s recommendations to discontinue running or aggravating factors identified during the examination and promote positions of relief.
• I would promote low intensity aerobic exercise if she can tolerate i.e. biking
• I would also hold on manual therapy for IE based on her current irritability level and her subjective reports of “9/10 unbearable pain” and “10/10 unable to carry on any activates” and wait to see how she responds to education and exercise.6. How would you educate the patient regarding our findings and her upcoming surgery? If this means a suggestion of no surgery, how would you address the Doc?
• First I would determine which surgery she is ready to undergo. I would not directly recommend against surgery but I would promote attempting a conservative PT route first before jumping into surgery. In regards to communicating with the doctor I would make them aware of the subjective and objective findings and see what their findings were and his/her indications for surgery. Additionally I would express our potential role can be in the rehabilitation process for this particular patient.Based on the subjective what is your immediate differentials?
– Lumbar facet dysfunction
– Lumbar radiculopathy
– Lumbar discogenic pain
– Lumbar DJD?Does she sit or stand for work? Does working increase her sx?
Based on the objective findings are there any other tests that you would have performed?
– Slump (more provocative if inconclusive SLR?)
– H&I testing
– endurance testing?
– Prone instability testing; vertical compression test
– DTR’s
– Interesting that she has WNL lspine flex but refused to attempt to pick an object off the groundWhat is your primary hypothesis?
– Lumbar facet dysfunction w/ catastrophization
– especially if she feels that her pain has increased because of insurance cutting off her opioidsWhat interventions would you have performed on the first day?
Education: addressing her yellow flags, describe to her the importance of continued movement and activity. Express to her that the tissues affected during the MVA have healed by now and we are not damaging them by moving. Additionally I would educated on setting up work ergonomics standing or sitting.
Due to increased fear of movement I would start w/ simple supine exercises LTR’s, SKTCWould this be a patient you would perform manual therapy with, or would you keep your interventions all active? If you did any manual therapy, which techniques would you choose?
Erik I think you make a great point in attempting to identify if she received any manual therapy in the past and their effect on her symptoms.
I would perform MT with this patient explaining to her its role in treatment. I would explain to her these techniques are meant to give you some relief so that you can perform exercises/activities in an attempt to promote independence and active exercises. Based on the information I would perform slidelying flex/rot mobs to Lspine Gr I-IIAfter reading the article I would consider Tspine manipulations but probably not on day 1 due to her yellow flags that I would like to continue to address during subsequent visits.
After reading these few articles posted for discussion I feel more comfortable with educating patients on their prognosis for treatment and setting patient expectations from day 1. As previously mentioned each patients individual symptoms will drive decision making for each intervention to provide them the best outcome. These combination of articles have highlighted many different approaches to treatment that could be implemented into a patient’s POC. Like Jeff mentioned however, this pathology takes time to heal no matter what interventions are performed.
I really liked how the second article implemented their strength training protocol, implementing maximal dorsiflexion of the toes to place maximal stress through the plantar fascia. This is something that I will definitely explore especially early on in treatment based on the results of the study.
I too am not dry needling certified so I have never considered it as an intervention for plantar fasciitis symptoms. With that being said dry needling is never the first intervention that comes to mind when treating any of my patients. If patients are improving with less invasive techniques, ie, manual techniques, stretching/ strengthening exercises, orthotics, taping etc.. then those would be my first options. I believe providing them education, and self management techniques will promote more long term independence as compared to providing them relief with dry needling and them feeling dependent on it for improved symptoms.
The findings of the article and their conclusions are definitely appropriate based on their findings. One part of their conclusion that really stuck out to me was, “real dry needling produced medium reductions in foot pain beneath the heel, its value also must be considered in the inconvenience of the intervention.” does not have me convinced that dry needling is the intervention for plantar fasciitis. It will be interesting to see what conclusions future research will have regarding dry needling for heel pain.My biggest takeaway from this study the significant changes seen in NPRS and FAAM after the initial two weeks of constant TCFO usage. As Jeff had mentioned being a young eager clinician I want to get my hands on patients decrease their symptoms with manual techniques and stretching. After reading this article I think a lot of treating this pathology like any other pathology comes to educating our patients. Finding ways to decrease aggravating factors to allow our tissues proper healing time before implementing stretching, manual or stretching interventions is key for positive long-term outcomes.
I personally do not make any custom orthotics or make many recommendations for orthotics in my practice. I will however discuss with patients choice of footwear and ask them about how they feel in their different pairs (i.e. dress shoes, tennis shoes, heels, etc.) of shoes and approach the conversation in that manner. I have yet to consider taping either but I could see how that could have a similar effect to the TCFO as the article had mentioned providing support to the plantar fascia and reducing the pull with each step. It may be something I try to implement if I come across the case of PF that is not progressing as expected.
I too believe that resting foot type (pes planus, cavus, neutral) will determine orthotic recommendation or use for plantar fascia pain. As Dhinu had previously mentioned and Jeff stated with pes plaus or cavus we are dealing with two separate issues, (overstretching, over shortened). I believe the role of an orthotic in these particular cases would not be to correct the actual “deformity”, but to redistribute forces along the foot to decrease the stresses placed on the plantar fascia.
Jeff to your question I agree with your questioning of the protocol to stretch a foot that may already be irritated due to overstretching (pes planus) of the plantar fascia. Maybe these patients would benefit from a strengthening protocol ie short arch springs, towel scrunches, or SLS? I wonder what everyone else thinks as well.
1. Based on the subjective findings, what are you immediate differentials? Do you ask any more probing questions?
– SA impingement, RTC pathology, partial tear, ACJ arthrosis, Labral pathology
– Any change in programing or activities at the gym
– Pt goals
– Imaging?
2. Based on the objective findings, are there any other tests that you would have performed?
– I agree with Cam that you definitely worked systematically to rule out cervical involvement
– Potentially looking at other aggravating factors during eval even through you hit his main c/o
– Interesting he had pain w/ pushups but no p! w/ bench press under 275… I wonder how his bench form looked?
3. What is your primary hypothesis?
– I agree with you
4. Do you agree with the order to have the “functional testing” after the rest of the exam? Would you have done this day 1?
– I agree with your order of testing especially if you felt that his symptoms were highly irritable and may have affected some of your other objective examination findings. I personally do not have access to a barbell bench at my clinic so I may have performed a push up prior to initiating my objective examination especially if his c/o were benching at higher weights knowing that I would not be able to replicate his exact aggs.5. What interventions would you have performed on the first day? More/less/different MT? Different exercises? Let me know your thoughts.
– I would provide education on resting posture at work to promote improved thoracic extension as well as promote improved resting GH position
– Education on activity modification at gym, dec weight, intensity, repetitions to avoid aggravating factors; I definitely like how you educated him on improving his push pull ratio.
– I agree with your exercise prescription; I definitely would have included some form of scapular retractions and Tspine extension over FR
– I too find that I do not have too much time during my evaluations to perform manual techniques on everyone. Typically if indicated I will try a quick manip to improve pt buy in and have them leave the clinic feeling better. Or during assessment if a restriction is identified go right into a quick round of treatment for said restriction.1. What are your top three diagnoses based on the subjective information? (ranking order)
• Cspine radiculopathy
• TOS
• RTC pathology
2. Based on the subject info, what would be your top priority objective tests and why?
• Cspine radic cluster (Cspine rot, ULTT1, Distraction, Spurling’s)
• UE neuro screen (myotomes, detmatomes, DTR)
• 1st rib
• TOS
• Resting posture/work ergonomics
• Grip strength
3. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
• Mechanical Cspine facet dysfunction R C4-5 with dural irritation
i. LSB and R rot painful & b/l front quadrants painful
ii. Pain w/ R UPA and CPA C4-6
iii. Myotomal weakness C5
4. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient? (Key information, keeping in mind this is a one hour eval)
• 1st rib assessment
• TOS assessment
• Work ergonomic observation
• Hand dominance?
5. What would you test in the next follow-up treatment session?
• 1st rib and TOS
• DCF endurance
• Functional testing (wall push up or push object – agg factor)
6. What would you have given patient for her initial HEP?
a. Postural education
• Work ergonomic recommendations
• Scapular retractionsI too was surprised at the outcomes and conclusion of this study. It definitely contradicts my beliefs and my outlook on PT’s role in the management of hip OA. As new clinicians it is important to keep an open mind and critically appraise arguments and articles that that may challenge our beliefs. With that being said I still believe that PT is superior to sham treatment for the best outcomes for our patients.
The wording of their conclusion will make many therapists turn an eye to this article. Looking at the results and outcomes, both groups made improvements from baseline in self-perceived pain levels. I was more surprised at the extent at which the sham group improved. Jeff I too found it interesting at the lack of improvements made in jt ROM and strength in the PT group. I think frequency of visits could have been increased especially in the earlier phases of rehab to review HEP and ensure that it was performed correctly. I feel that this article shines a bigger light on the effect of the placebo effect as opposed to the lack of efficacy of PT for patients with hip OA. As we talked about earlier this year, placebo is a powerful tool that can be utilized in the right situation.
Cam & Jeff- I agree that there were limitations and a few things I would change in the methods in regards to how to quantify compliance with HEP and how to determine if the prescribed was performed correctly. I definitely think this article can be beneficial for the right patient who is not improving and may benefit from an alternative approach to treatment.
Erik in regards to the best way to test ratio I think it depends on the patient in front of you. For example if you have ruled out all other differentials and you are attempting to rule in AP for a patient who is coming in w/ c/o inc pain levels, >7/10 I’d probably lean towards a 1RM to determine ABD:ADD ratio. As compared to another individual presenting with lower pain levels who may be in a sub-acute or chronic stage a 1RM may not reveal underlying fatigable weakness. I believe that the key is to be consistent with how we perform these test and measures as the article mentions, but I would typically lean towards a 3RM so that an average can be taken and fatigable weakness can be identified.
I also appreciated the fact that this article brought us back to the basics and did not try to overcomplicate the evaluation and examination of AP. Sometimes I find myself trying to group patients in categories when they don’t belong in one. As long as I am diligent in ruling out red flags, identify impairments that can be addressed and progressing/regressing patients appropriately they will often times get better.
I really enjoyed this second article and how it applies to everyday practice. As a new clinician it’s easy to fall into prescribing clamshells for glute strengthening exercises for each patient. We need to take into consideration all the functions of the Glute max and med have outside of just lateral rotation/abd. I found it very helpful how the article highlights and differentiates exercises into low, mod, high, and very high level activation. While it would be amazing to prescribe each patient with glute med weakness slide planks, single leg squat and single leg deadlift these may not be the most appropriate exercise for the patient based on their symptom presentation.
This article will definitely be a resource I turn to for my patient that I am seeing for glute med tendinopathy as we progress from isometrics to more functional based exercises that focus on progressively loading her glute medius tendon.
This article was an awesome resource for a recent evaluation I had this past week for lateral hip pain. Her subjective and objective presentation matched those mentioned in this article almost exactly. I have a better understanding of how mechanically driven this pathology is and the importance of educating our patients on neutral hip positioning during functional tasks, sleep, and exercise. I will definitely start implementing some of the isometric strategies proposed by the article, now knowing some of the analgesic effects it has on the body. For example with my patient she was unable perform an isotonic sidelying clamshell against gravity due to pain, most likely due to her hip resting in an ADD position. This upcoming week I will definitely see how she responds to an isometric clamshell with a pillow between her knees.
Jon to your questions about volume/intensity of isometric contraction I typically educate my patients that less is more in the beginning, with and pain free/ low pain levels being the key during the exercise. I will typically start with ~50% contraction for 5-10s holds and modify from there based on their tolerance, but now after reading the article I will considering starting with even less intensity.
1. What are your top three diagnoses based on the subjective information? (ranking order)
• Myofascial strain
• Disc referral
• Facet referral
2. What is your top clinical diagnosis based on the objective information and why?
• Myofascial strain
i. Pain with all planes of lumbar motion
ii. Inc muscle turgor bilat
iii. lack of discogenic referral pattern
iv. pain w/ active hip extension but not passive
3. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient?
• Subjective – screening questions for possible concussion even with denial of hitting head – due to two MVA within a month, HA, dizziness, nausea, light sensitivity, sound sensitivity, loss of concentration?
i. Sleep disturbance?
• Objective
i. Repeated motions?
ii. Cspine quadrants
iii. Lspine quadrants
iv. Cspine ligamentous testing
4. How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this patient regarding prognosis?
• I would use the findings from the objective and subjective exam to support my explanation to the patient. Educate the pt that her body is still most likely in a hypersensitive state following her two MVA’s. I would also reassure the pt on prognosis and POC of how we are going to get her better and reach her goals.
5. How do you expect to progress your treatment program over subsequent visits?
• I would focus on pain modulation early due to her self reported pain levels educating her on the importance gentle continued movements in the her painful ranges. Manual therapy STM and mobilizations to tolerance at identified lumbar and cervical regions.
• Incorporate more functional exercise as pain levels decrease such as squatting or bike for cardiovascular exercise to promote blood flow to affected regions and promote healing.After reading this article I brought it up the findings to one of my patients recovering post meniscectomy and she was very surprised to hear the results and mentioned she never considered a conservative route. This was not a huge surprise to me and goes in line to what the article mentioned about APM being among the most frequently performed procedure in orthopedic surgery.
In my short time as a clinician I have seen the positive outcomes from both sides of this study. My biggest takeaway is that we as health professionals need to take the patient’s views into account when determining if surgery or conservative treatment is the best path for them. More often times than not these patients images are being ordered by orthopedic surgeons who read their results and are quick to recommend surgery. People usually want the quick fix for their pain so they don’t think twice about surgery, but what if patients do not want to get cut into? We need to advocate for our profession to patients and surgeons about the positive outcomes of conservative treatment for these injuries. Patients need to be properly educated about the different treatment options and involved in the decision making.
Jeff I agree that the objective and design of the study were interesting like you mentioned. Do to the nature of the study being a RCT they needed to control the variables which is most likely why each patient did not receive individualized treatment. That same thought crossed my mind when reading about the APM group and their intervention being simple HEP to perform individually.
AJ thanks for sharing this case with us.
While your patients presentation is unlike any I have come across this early in my practice it reminds of someone that Kristin and I have seen during my mentoring hours. The patient is coming in for plantar fascia pain and is responding well to therapy. However the referring doctor insists on his patient receiving US as a part of his POC. In this case we have the ethical dilemma providing what we believe may be the best treatment approach to the patient, while at the same time not upsetting our referral source by going against their treatment recommendations. We have decided to incorporate US into some follow up visits to appease the referring physician despite its lack of evidence in the research.
In regards to the case you posted I believe it is ethical to allow patients to dictate a portion of their care even if their request lack evidence, if it will improve patient buy in and compliance. Typically during my evaluation I will as patients if they have been to PT before and if so what they felt worked best for them. Based on their response I try to work with them to utilize different exercises or techniques they believed worked best for them while prefacing it with, “we might try a couple of different things here because everyone practices a little differently.” If a patient is adamant about receiving passive modalities during their treatment session I would like to think I would handle it similarly to you where we try and find a way to keep both parties happy, working together to make them feel better.