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1) Is there any more information you would have gathered during the subjective? Are there any other outcome measures you would have administered?
-Was she the driver or the passenger is the car? speed of cars? seat belt?
-Hx of headaches, neck pain, shoulder pain
-Any concussion symptoms (loss of consciousness, difficulty concentrating, etc)
-Persistance of symptoms?
-Possibly NDI2) Based on body diagram and subjective exam is there anything else on your differential list? Is there anything you would change on mine?
-I think you have a strong list of differentials3) Considering irritability would you have changed your objective exam? What would you have done differently?
-While you stated the irritability was mod-severe, I would like to know the persistance of symptoms, to see how symptoms responded after being increased.
-How were R rotation, SBR, extension, and the other quadrants? Was the cervical ROM limited?
-Also, you did state you performed them over two visits, so it seems as though you may have altered your objective exam for that reason. I would be interested to see which findings were on initial eval and first follow-up and the time between.4) What is/are your primary hypothesis or hypotheses?
-cervical facet dysfunction with Myofascial involvement5) What would your PICO question be for this patient?
-In patients with cervical facet dysfunction does PA mobilizations and exercise improve ROM and decrease disability compared to exercise alone.Working hypothesis and differential diagnosis:
a.) What is your working hypothesis regarding this patient?
1)cervical discogenic dysfunction with acute rotator cuff tearb.) What are your next 2-3 differentials? (Ranking order)
1) labral tear, instability
2) C6/C7 facet arthropathySpecial testing:
a.) What are your thoughts regarding the special testing chosen for this patient?
-I feel as though you did special tests for both cervical and shoulder which is good but did not perform enough of each cluster or enough to better help rule out or rule in a specific possible diagnosis. For example you performed two labral test and then two impingement tests, and two radiculopathy tests.b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?
Cervical – distraction and compression
Shoulder – Load and shift, sulcus, active compression, ER ROM and strength,
AC and SC – screen to rule out
Palpation-which periscapular musculature (any referral/tingling associated w/ palpation)Clinical Pattern:
a.) Does this patient’s presentation fit a clinical pattern?
At this point, I don’t see a clinical pattern but definitely can see the puzzle pieces fall in to place especially with some more testing.b.) Briefly, what are your thoughts regarding his headache?
Hard to tell with information given. If the headache has been before the MOI it may be cervical related. If after the MOI, it may be related to muscular compensation d/t the shoulder injury. With flexion as well as L side bend it makes me think it may be myofascial-related.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 believe they are two different injuries that are in close proximity and therefore the symptoms may be overlapping.b.) Are there any red flags?
Not that I can see.Treatment
!) periscapular strengthening/neuro reed – prone Y’s/T’s to assist in decreasing anterior tipping
2) STM to periscapular musculature
3) Posture educationI’ll be honest, I am not a huge podcast person, so I can’t be of much help in that area. I do follow a good amount of people on social media, mainly Facebook and Instagram.
Instagram
physiotutors = Special tests, clusters, EBP
motionrx_ = exercise progressions
physicaltherapyevidence = Posts with evidence-based backing
elitehp = Exercise progressions, techniques, etc
modernmanualtherapy = BFR studies, random PT-related posts
the_manual_man = Interesting manual techniques (dude seems arrogant)
mikereinold = testing, manual techniques, EBP, exercises, etc.
drjmike = Sports Performance, exercises
themvmtpts = Associated with PTCOFFEECAST
motusspecialists = Exercises prorgressions
functionalmvmt = FMS Instagram
PhysioOsteoGram = Referral patterns (Awesome reference)
theperformancedoc = Exercise prescription
strengthcoachtherapy = Sports rehab, exercise prescription, good infographics
theprehabguys = exercise prescription
VOMPTI = ObviouslyFacebook
AAOMPT = Self-explanatory
Physio Memes = We need some laughter
APTA = Self-explanatory
Physio Network = Evidence, articles, etc.
ChoosePT = Stay up-to-date
Physiotutors = Special tests, videos on techniques
Modern Manual Therapy = BFR studies, random PT-related posts
PT Pintcast = Pt-related posts, podcasts
VOMPTI = ObviouslyI have no personal experience with TMD, so I have no golden nuggets to give you unfortunately.
I see that you cleared the cervical spine with APR with no limitations or symptoms but did you do any quadrants or combined movements? In the articles provided, cervical spine was involved with majority of TMD cases and therefore I am slightly skeptical that there were no limitations or symptom provocations especially with concurrent headaches. Also did you do any PPIVMs/PAIVMs of cervical spine?
Objective
Were the limitations found with TMJ movements active or passive and did you perform any accessory mobility testing of the TMJ?Interventions
Cervical isometrics – With no limitations or symptom provocations with cervical testing, what made you choose this intervention?
Did you think about utilizing any of Rocabado’s or Kraus’ interventions to directly address with limitations found in the eval such as: rest position of tongue for promotion of diaphragmatic breathing which may help with relaxation, control of TMJ rotation which could prove as a good NM control intervention, Rhythmic stabilization technique for isometric strengthening and relaxation via reciprocal inhibition, touch and bite for proprioceptive re-education, and other TMJ isometric exercises
Lastly if you find/found limitations with accessory motion you may be able to teach her some self mobilizations for HEP.Awesome job and good luck with future treatments!
Awesome job! I am not at all envious of you being the first to present but so far it is looking good. I look forward to hearing the rest of the case.
Questions:
1. What are your top three diagnoses based on the subjective information? (ranking order)1)Cervicogenic HA (Upper Cervical facet dysfunction)
2)Cervical muscle strain (SCM?)
3)Lower cervical facet dysfunction with referral2. Using your number one differential, what would you expect to be (+) during the objective exam to support your hypothesis?
(+) CFRT L compared to R
(+) PPIVM C1/C2, L more limited than R (d/t rotational deficits), Possible tenderness L compared to R, Possible referral of HA
(+) PAIVM, L more limited than R (d/t rotational deficits), Possible referral of HA
Limited cervical extension, increase pain3. What is your top diagnosis based on the objective information and why (asterisk
signs/symptoms)?1) Cervicogenic HA d/t cervical joint dysfunction
-L UPA of C1 and C2 relating to p2 with HA
-(+) L CRFT
-p1 with B SB,B rotation, and extension (facet in nature)
-p1 with CPA C%/6/7 (facet in nature)4. What Manual therapy and HEP would you give the patient on the first day?
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Manual therapy
-PAIVM to C1/C2 and other segments with decreased mobility
-STM to suboccipitals, UT, LS, SCM (if shortened)-
HEP
-Education – posture, exam findings, prognosis
-Cervical rotational SNAG
-Cervical extension SNAG
-Chin tuck 3-5s hold 3×20 (improve endurance/progress as tolerated)
supine->sitting->sitting (with functional shoulder movements)
-TB row with chin tuck5. is there something that doesn’t sit well with you in either subjective or objective? If so, what other subjective questions and objective tests would have been helpful regarding this patient
Case?One thing that I would ask as far as irritability goes, is how long does it take for symptoms to dissipate. I see that you have irritability as minimal and symptoms ease with massage instantly but do symptoms persist for long periods of time otherwise. Especially since he is only able to drive for 15 minutes currently.
Objectively did you find anything palpation-wise as far as soft tissue goes? Any increased muscle tension, spasms, trigger points, etc? With relief coming from his spouse’s massage, I would expect some potential soft tissue involvement.I agree that TNE isn’t necessarily something that needs to be addressed with every patient. In regards to the patient who is in the acute stage of post-op recovery, I believe that having an open communication and educating them on the realistic expectations of their recovery is one of the most important things that we can provide. I have noticed more and more that a lot of patients who have had surgery, have no idea what to expect as far as recovery goes. That includes pain expectations, movement restrictions, prognosis for return to PLOF/sport/work, and the amount of time and work that is required to return to their normal function.
Coming in to this weekend, I was expecting to hear a similar pain education talk that I have received multiple times throughout PT school and lectures at CSM and boy was I wrong. I was not expecting to delve so deeply into the “bottom of the iceberg” but figured it would be focused on the visible portion of the iceberg or the area of pain science focusing on teaching us how to portray this plethora of information to our patients. I was struggling with this throughout the weekend until I changed my mindset.
Looking back, it was naive of me to think that this course would just hand me a few sentences or phrases to explain the pain phenomenon to my patients. Even if we did receive those sentences or phrases, would those sentences or phrases even resonate with our patients without a better and more in depth knowledge of what pain truly is? Lorimer Moseley gave the example about dry needling and I paraphrase (poorly), even without the needle as long as the PT believed that they were in the correct spot and that they were affecting change in the tissue then it had an effect on the patient. Can this apply to the topic of pain science and education? For example, if we were to have been given a few sentences and phrases to tell our patients (top of iceberg) but didn’t know or believe how the bio, psycho, and social aspects of the human and pain interacted (bottom of icebergurg) would that therapeutic pain science discussion be beneficial to the patient?
Lastly, I came into this conference thinking that I was pretty decent at giving a therapeutic neuroscience pain talk to my patients. I would always use the kitchen smoke detector as an analogy, for example:
Me: “Pain is the alarm system in the body, it does not always mean that there is damage in the area but is more so telling you that there is a potential for damage. Have you ever been cooking on the stove top and you put some olive oil on the pan and it starts to smoke a little bit and then all of the sudden the smoke detector starts to go off?
Pt: Nods head
Me: “Imagine the smoke detector as pain alerting you that there is a potential for danger. In this case, the smoke detector is telling you that there is a potential for a fire so go check it out. The same way the body tells you there may be something wrong, check it out (go to a doctor, they run scans, perform different tests, etc.)
Me: So you hear the smoke detector and the first thing you do after yelling at it, is to check the sources for danger. You realize that the oil in the pan is smoking but there is no actual fire but just a potential for it. So in your case, you have gone to a doctor and/or me and we have checked for the “fire” (red flags, fractures, etc). Now that we have made sure there was no fire, lets turn down the stove and get rid of the smoke, aka lets start some gentle movements in order to get back to what you want to do.”While I still like my analogy and I have been given good feedback from my patients, after this course I believe I will need to go back and change some things up. I really like the visual and idea of how pain creates a larger buffer and alters the threshold of when it is experienced. I’ll keep you all updated if I think I have something that works well.
Hi my name is Erica Binzer and I work at Move Better Physical Therapy in Charlottesville, VA. I graduated from PT school at Old Dominion Univeristy in 2018. I enjoy working with a variety of patient diagnosis in the outpatient setting. I look forward to learning new manual techniques and improving my clinical reasoning through this course.
Hello all,
My name is Nate Swarringim I started my career as a PT June 2018 in outpatient orthopedics, graduating from Old Dominion University. I have a strong interest in sports medicine hoping to lean that way in the future. I utilize manual skills consistently so hoping to learn to treat more specifically.
Hi everyone! My name is Barbara Semple and I work at the Jackson Clinics in Lorton, VA. I’ve practiced outpatient orthopedic and sports rehab for my whole PT career. I look forward to advancing my clinical reasoning and clinical decision making skills, while also improving my manual skills. Excited to meet everyone and spend time over the next few months working together!
“Placebo and nocebo phenomena are influenced by practitioner behavior, which affects both patients’ and clinicians’ experiences. This occurs at the point when the clinician’s wish to do good meets the patient’s desire to be helped. This phenomenon, coupled with therapeutic interventions, is where the art and science of medicine work
together—a mixture of the practitioner framing a positive therapeutic experience
and the use of evidence-based interventions.”I have read and reread the quote above over and over and have come to the conclusion that placebo, in itself, is not the most powerful treatment tool we have but placebo coupled with evidence-based interventions is.
Throughout schooling, the importance of verbage and positive language was ingrained into our studies. In one of the pain TNE lectures we discussed SIMs (safety in me) and DIMs (danger in me) and were presented an article discussing the effects of communication skills with our patients (attached below). This article states that possible benefits of effective communication skills include improvements in outcomes, adherence, and accuracy in problem identification. I have found myself altering not only the way that I speak but also how my patient’s speak about their impairments or diagnoses. For example, I have plenty of patients with knee pain or post-op TKA or ACL that refer to the affected leg as “the bad leg” which I quickly correct them to call it their “right” or “left” knee. A simple change in wording de-threatens the language and may redirect their view on their impairments or diagnoses.
I believe that placebo can be a very beneficial tool but can also be be detrimental if used without clinical judgement. One example, which I have been struggling with in my clinic (I may be biased), is the use of modalities such as TENs with my patients in order to increase my billable units…I very rarely, if ever use TENs due to the fact that I do not want my patients to become dependent/reliant on the feeling or effect that TENs has, as it is not addressing the impairments and is a passive modality. While it may decrease their pain by blocking nociceptive pathways with the pain gate theory, it has no lasting effect (that I know of) but the dependency of having “the electric zapper” at the beginning of the session counteracts the idea of the patient becoming independent and self-reliant.
This article really hits home in the fact that it focuses on the biopsychosocial aspect of care and how we as clinicians need to focus on our patient’s needs and expectations, as noted in this quote “…we should strive to discover the patient’s expectation and then deliver and exceed it to the extent that it doesn’t cause more harm. If a patient’s expectation could cause harm (eg, an early magnetic resonance imaging scan the patient doesn’t need), the onus is then on each of us to reshape the patient’s beliefs to be consistent with best practice.
Hey everyone, my name is Brandon Reynolds and I am currently a VOMPTI resident working at Pivot Physical Therapy in Richmond and mentoring with Dr. Kelley at Phoenix Rehabilitation and Health Services in Goochland, Virginia. I have been working for a year at Pivot in a general outpatient orthopedic clinic seeing various diagnoses. I graduated from Lynchburg College in May of 2018. I enjoy working with a variety of populations but favor working with the athletic population. My goal for this course is to become a more well-rounded clinician allowing me to utilize the skills gained through residency in a more comprehensive and efficient manner. I look forward to meeting everyone this weekend
Hi all. My name is Derek Xie. I work for MedStar NRH in Baltimore, MD. I graduated from Marymount Univeristy Aug 2018. I have been practicing for almost one year. I am in an outpatient orthopedic setting that has a combination of athletes and general ortho. I enjoy working with patients that span from athletes to the typical TKA. I am looking forward to VOMPTI to further advance my clinical reasoning and manual therapy techniques. Looking forward to meet everyone this weekend!
Hello everyone. My name is Nick Grillo and I am a PT for BioMechanic Physical Therapy in Lansdowne, VA. I graduated from PT school at Boston University and have been practicing for over five years, all in outpatient Ortho. I am hoping to continue to further my manual therapy skills as well as my clinical reasoning across all body parts. I most certainly have aspirations of taking the OCS in the future and have heard only amazing things about the VOMPTI courses. I look forward to meeting all of you and sharing the next six months ahead.
Hello Everyone. My name is Claire Guida. I’ve been working in OPPT in Winchester VA at WOA PT for 11 years. I see people from the age of 14 up to 96 y/o, primarily for orthopedic issues. We also treat Balance, Neuro, & Vestibular Issues as well. Previously, I worked in Acute Care for 7 yrs at WMC. I worked in OP PT/Industrial Rehab in Southern VA my first year out of school. I graduated from Ithaca College in 1999. I’m hoping to improve and update my knowledge of evidenced based practice and hone my manual skills. Most of my fellow clinicians in our office have taken VOMPTI, so I’m hoping it will help with the continuity of care in our clinic as well.