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Please review this article – posted Weekend 3 in the light of this patient case.
I love this article for the Clinical Reasoning/Exercise Prescription (library builder)
Post thoughts on the specific patient presentation from points in the article
1.I’m in agreement with Erik. You did a nice job with TOS and objective testing, as well as with your clearing screening. Personally, I have had limited experience with TOS. But for this specific patient, it sounds like addressing work related and psychosocial factors would be particularly beneficial. I would stick to your objective asterisks for treatment as you determine which structures may be involved and what treatments are beneficial.
2. I don’t typically give self-neural mobilization the first day in order to determine their response to the initial treatment. If that is a technique I’m considering as a part of a home exercise program, I’ll have them perform it during the initial evaluation or treatment; then prescribe it the next visit if there was no flare up.
4. I would continue to use your subjective and objective asterisks to guide treatment. I also agree with Scott that focusing on one potential culprit at a time will give you more information. I would continue to assess and re-assess after each different treatment and not muddy the waters. For example, if you perform soft tissue mobilization along the neural structures and mobilize prior to reassessment, it would be difficult to determine if both or which of those techniques was actually beneficial.
5. That’s a really difficult conversation. If it were something one of my patients was seriously considering, I would be potentially referring them back to the referring physician or primary care provider for further medical management. It’s such a life altering decision; I would want multiple health care professionals helping guide this patient. I would address this after determining the best patient specific approach, i.e. what kind of verbiage is appropriate and how the patient may react to what you say. As Scott said, I have not had this conversation with a patient but it’s a good reflection point as it is going to come up in the future.
What structures are being evaluation/stressed with the positive TOS tests that reproduced her sxs?
Those positive tests load specific structures in the thoracic outlet region.
The information gathered and the reasoning should guide specific treatment techniques directed at those tissues.
All that being said; a large percentage of these patients with a structural anomaly do not do well with conservative care.
Great post August. I love all the points it brings up.
I feel like as I treat more and more patients that I use less and less specific spinal joint assessment (PIVMs especially) to evaluate; maybe with the exception of cervical spine. However, like everything we do in PT – understanding the limitations of the evidence is an important part of good clinical decision making.
I believe that improving your touch, and psycho motor skills of assessing specific joint mobility is an important part of learning to be a manual therapist. It is only one piece of a comprehensive evaluation, that may lead to specific directed treatment to improve mobility (by whatever means – mechanical, neurophysiological, or placebo); and teach people how to move more efficiently.
Those are my first thoughts – again great post
Hopefully ALL our residents read, think and contribute to this discussion
Happy Holidays
As someone who is also challenged with my size versus patient size, I found this article to be very insightful. I know that over the duration of several weekend courses, I have been practicing my manipulative techniques. I have found that lowering the table to get my body weight over the patient and issuing verbal cues to better inform them of what position I would like them to maintain has helped my overall success with the technique. I believe I still struggle with some larger patients when utilizing the supine thoracic manipulation technique because I am unable to maintain my hand position to adequately create a barrier of resistance. When this happens, I tend to revert to the prone technique. I am always interested in modifications that I could utilize to perform techniques such as this more successfully.
Did you assess her position (grip/grasp, posture) on the motor cycle?
Did you assess her functional biomechanics with other provocative activities (in the barn)?Especially in light of very low irritability – Don’t lose sight of the basics (functional provocative testing), ergonomic assessment/advice – related to entire kinetic chain, cervical/thoracic/lumbar posture related to increased tissue stress on the elbow/wrist.
Sorry if I missed that in the discussion.
That is really interesting August, did the CHT mention what her thoughts were regarding the use of LE braces due to the risk of entrapment? Whether it should be utilized in the short term, or how to educate patients in order to potentially avoid that issue.
Great case Nic.
A few thoughts, I think everyone has mentioned neurodynamics, so I would agree that having a baseline may be beneficial as well as evaluating cervical mobility. What digits/area did the patient report having her numbness and tingling? If not something you address right away, I would be curious if providing her with nerve glides or working along the nerve track affected her symptoms with riding her motorcycle. In terms of chronic management, she has been taping her wrist, but what were her thoughts on utilizing a brace at work in order to unload those structures while working towards symptom free performance? In terms of taping, I have utilized it for patellofemoral pain in the clinic. I have had some success when using it to decrease pain with exercise performance. With scapular strengthening, I feel like challenging her functionally with similar endurance activities she has to do at work and trying to pick up and address deficits may provide distal relief.
Did you have her fill out any functional outcome measures (DASH, QuickDASH, etc.)? This maybe useful in structuring your goals and tracking change over time. Additionally, has she noticed any changes in her symptoms since starting therapy? Re-hashing where she started and changes that have occurred, whether it be the intensity of her symptoms, the duration, or the time it comes on, may be useful to discuss as it may point out positive changes and provide you with an idea of what she would like to be able to do prior to being discharged. As this is a chronic condition, maybe consider seeing her two times a week until you have seen a plateau in care and she is independent with her home exercise program. She may be someone you decide to see once a week or every other week to check up on to monitor and change her exercises as appropriate.
August one of the progressions that I find helps patients when progressing DNF training to standing with UE challenge is with use of a laser. I have them go into a chin tuck position and I place a sticky note on the wall, I next have them perform UE challenges (shoulder ext,scapular retraction, bilateral rows) while maintaining the laser on the point. I find the visual que really helps some patients maintain the position.
I agree with your thoughts on seeing the comparison of using the 10 minutes on low grade mobilizations instead of a thrust technique. I tend to spend more time doing low grade mobilization and soft tissue work, along with ROM exercises vs a thrust technique. I think this is partly due to my lack of experience and confidence performing a comfortable thrust techniques for the patient.
In terms of other screening tools and objective measures, as Austin mentioned, I would be interested to see if palpation of the anterior and posterior musculature reproduced any symptoms. Additionally, if there would be any change in active cervical rotation when slackening the upper trapezius. Based on the patient’s symptoms, the vigor of the exam seemed appropriate. If I am going to try to provoke all of a patient’s symptoms, it is important to me that they have only mild to moderate irritability or I have determined a position of relief, which can be difficult at times. I notice that I tend to build a greater therapeutic relationship with patients when they see that I can reproduce and alleviate their symptoms. I also agree that using asterisks/comparable signs to be very beneficial for me as well as the patient. As Erik mentioned, I like to try to have at least one asterisk that is not pain dependent. I have noticed that having 2-3 comparable signs is a good number as when you are comparing from one visit to the next, the patient’s irritability/symptoms have hopefully reduced and something that once reproduced symptoms may no longer be positive the next visit.
I have used some form of DNF training with all patients with neck pain, and tend to progress in a similar fashion to how everyone has described. In addition to adding DNF with upper extremity strengthening, I have had patients perform functional tasks as well. In terms of thoracic mobilization, I will utilize it with most neck pain patients, however it may not be in their initial evaluation or even first treatment. I mostly utilize a thoracic PA mobilization, as at this point in my career I am more comfortable with mobilizing versus manipulation. I hope to progress towards using more manipulative techniques as I become more comfortable with them.
Great article, Austin. I too am interested to see future research on this and how it will affect patient care clinically. I can relate to you, Justin, in that in my limited clinical experience I have not had many patients who are truly fear avoidant. In some cases where I believe someone may benefit from addressing some degree of being fearful of pain or movement, I have used more of an informational and education-based approach. I found reading Adriaan Louw’s book, Why Do I Hurt?, while directed more towards the patient population and not health care professionals, helpful as it provided some great examples of analogies for hypervigilance of pain and the effects chronic pain can have. With fear avoidance in particular, I believe it maybe important to get to know your patients first in order to gauge how they will react to the information you are providing them. Additionally, I have seen with some patients, just getting them moving, no matter what their complaint is, has changed their perception of pain and movement.
I think you all bring up some great points. Goal setting should be in-depth and personal to what a patient would like to get back to doing in their everyday life and not their life revolved around their injury/pain. August, I like the idea of the having a patient consider their goals in their own environment in order to identify problems they may not bring up in the clinic or during an evaluation. With goal setting, I think it is important to be an active listener and put goals in their own words. When patients have difficulty discussing goals, I have found that asking them about what kinds of activities they have avoided or have not done because of their injury/pain can open up dialog about goals that the patient may not have even considered.
Everything in moderation