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Great string of posts – sorry to be late into the chat, but I was busy in Scotland.
A few of these points have been made, but these are my main thoughts:
– When exactly was the injury relative to your Eval?
– All of your decision making is based on Clinical Reasoning through tissue injury principles, related to specific loading and assessment, time line, prognostic factors that we know determine return to play
– “Play” is different than return to Marathon running, regarding load on HS
– Why flexibility/lengthening early on – have an assessment that gives you info about where the tissue in the healing state (What might that be?)
– What are some of those prognostic factors in the literature that help determine extent of injury and help with return to “play” education/expectations?
– Primarily think about what angle of knee flexion resisted aggravated sxs (mid/end ROM – with IR or ER or neutral rotation)
– Why recommendation to avoid hills, and run more upright? – think about what those recommendations bio mechanically do to the HS?
– What decision making criterion did you use to advance graduated loading?
– I agree completely with Strain versus Tendinopathy; and that should guide your loading progression.I will not be on the conference call tomorrow – so hopefully these points help facilitate some more discussion
Cheers
Eric
Just another case of an MD making our jobs harder.
How can you in your right mind make a statement full of misinformation and FEAR to a mom with a child without adequate information. If there was real concern – open mouth motion series films should have been ordered. The concern should have been brought up after the films if there was any real concern.
When you do Google it – you think your child is about to die. No other presentations in this case except some “cracking” post operative.
Great exam Myra – I hope your treatment is not just repeatedly convincing the parents that there child is not at risk for death. Hopefully the child is young enough not understand the ENT’s inappropriate possible “diagnosis” and just move on as a normal kid doing whatever she wants to.
Another example of how powerful every word we say to patients can be interpreted or misinterpreted, creating unnecessary fear and possible disability.
IFOMPT was amazing – Adelaide Australia 2020 – put it your calendar
Cheers
Damn that T4 syndrome – I’d send him to Aaron in Winchester to treat.
Seriously – I’d move slowly with him and give it every chance to heal, as we know the majority of these get better on their own especially in a young fit 25 yo.
I’d suspect a big disc, possibly with extrusion or sequestration; but they heal as well.
Continue to monitor neuro each visit to make sure to progressive neuro changes- especially motor weakness progressing.
I most likely would not thrust, especially that there is a central neuro component; possibly related to old thoracic injury.
Also think all central canals are not created equal.
Like others said regarding neural dynamics, especially with a central component; should be slow/gradual based on irritability and response over the next 24 hours.
Keep him moving in a functional way as we know that helps; MET/pulleys with postural/body mechanic cuing/education to keep irritability low.
Low fear communication/wording, encouragement regarding the healing potential of these tissues – ie. “the annulus is just a ligament just like your ankle ligaments, and you sprained those tissues.”
Thoughts?
My thoughts keep going back to function with this patient – assessing functional movement; aggravating factors, sometimes an emphasis more on functional work/activity related movement assessment can be a more effective way to weave in education, and assess other biopsychosocial components may come out.
Who cares what her UPA at L4 on the (L) is, if she has to hold a horse’s hoof for 3 hours/day; then rides for 20 hours/week. Sometimes stepping away from our battery of “Special Tests” which have limited reliability/validity, and can just be provocative; as well as fear inducing when some are positive in non organic ways (TC post glide reproduce proximal hip sxs), then we are stuck trying to further explain those findings.
Bit of a ramble, but hopefully makes some sense and facilitates some additional discussion
I don’t want to beat this drum again, but I just can’t imagine that treating ANY of those multitude of impairments, special tests, movement dysfunction will ever get better unless she understands that her pain is not from the tissues.
These are incredibly hard patients to treat, but us not seeing all the signs and changing our evaluation and treatment, communication to addressing the biopyschosocial components after clearing red flags, needs to be the primary focus of treatment.
Here’s a good article to review on cuing with these patients – specific cues for specific movement dysfunction.
What other cues related to some ideas here?
You guys are killing it.
Great discussion – introspection, excellent thought out statements across the board.
I seem to lean more toward Nick’s points.
90% of people have a lower back pain episode in their lifetime. The majority are self limiting; many do not need to seek any sort of healthcare. How many Physical Therapists have had lower back pain? Alot. How many go seek care, miss work, become disabled? None. Education/knowledge of tissue, pain, healing, expectations of symptoms are part of our understanding of an acute nocioceptive event. Because of that knowledge, we cope/confront and move on.
Who we need to screen early on and begin PT early, are those with acute lower back pain that are at risk for poorly coping with the episode.
Those are primarily psycho social factors: Yellow flags. Related to emotions, beliefs, attitudes, behaviors, family, work factors.
We’ll talk more on Sunday.
We have screening/outcome tools to use to address these attitudes/behaviors (ODI/NDI, FABQ, PHQ-2; TSK, lots more). Utilizing them to recognize the patients that may require earlier versus later PT.
Keep talking – great stuff.
Reverse McMurray’s treatment- give it a try – no research – mild to moderate success, but worth trying
“Something that I don’t understand is no matter what we do a torn meniscus will still be a torn meniscus.”
We all have torn menisci, labrums (hip and shoulder), degenerative disc pathology, etc. – get the tissue to calm down (think “fat lip” analogy from hip labral lecture); improve the rest of the system to tolerate load better; primary goal should be restore full ROM (extension) as a gauge of irritability.I’d manually work on terminal knee extension, before strengthening into terminal knee extension.
With the patient Nick was referring to – we did a “reverse McMurrays” to “reduce” the meniscus. Osteopathic technique which works about 50% of the time. Internal rotation with a valgus load to open up the medial joint line, and cycle it through graduated stresses into full extension.
Again no research – just a technique to asses/re assess.
Alex – how does that differentiate contractile versus non contractile?
What is the contractile differential? Quad tendonopathy?