Forum Replies Created
-
Posts
-
Hey all – First, Casey – Way to get the discussion going! Good call.
A few quick thoughts –Any other diagnostic tests that would be helpful here?
Any other things you can ask in subjective to help you differentiate hip from back or glut med from hip OA?
Considered irritable? Both back and hip irritable? Would you be willing to be more vigorous in some tests to help differentiate while being more cautious with others?
What do you think about lumbar extension causing pain while quadrant does not?
After out of car, does his pain ease after several steps, then increase as he continues to walk? Specifically which pain gets worse w/ walking?
If you point out the trendelenberg to the patient in a mirror, does this look like his typical gait or has he or a significant other notice a change related to timing of pain being more significant at the hip?
Anything you see in the literature relating hip OA and glut med pathology?
Which part of his pain is worse with sleep? Can you have him try different strategies with sleep position to help differentiate hip from back and mechanical vs. non-mechanical?
Do you consider these symptoms to be load sensitive? I know that distraction and lying down aggravate, but would there be a scenario where the problem would be irritable to both loading and unloading?
If so, are there ways in your exam you can differentiate from hip/back using loading?Hi all – great discussion!
Jon – Glad to see you wanted to complete an SIJ cluster to help clear your differential list.
All – Flexion fingertips to floor, but SLR = 100 deg, anyone want to assess lumbar PPIVMS in flexion? If so, why? How did lumbar biomechanics look in flexion?
Curious what part of her vocab list you chose to parallel and which parts you might have chosen to help her re-think.
Looking forward to the discussion tomorrow!
1. To better understand irritability: How long looking into a microscope or computer to agg? How about R cervical SB or extension? Immediate aggravation? Does he need to stop the activity or can he sustain the activity or position? Which symptoms, local or referred are reproduced with each activity? How long to ease with movement?
A.J. Thanks for the post! Have I ever seen a pt. like this before? Ha! :-) First, I would say, by retrospective reassessment, you definitely made the right choice since the patient is so much better! I believe your skills in paralleling with the patient by listening to her intuition/values/beliefs were a positive factor in her progress.
Having said that, I hate it when this happens and find the situation very difficult to navigate. #1, there is always that terrible feeling that you get when you physically are the one rolling that U.S. down the hall to a room. Secondly, these patients are such a project, I hate spending time with them doing something that I would not have even considered in their treatment plan w/o their insistence.
I like that you made the deal with the patient, ultrasound AND active treatment. Also, when in this situation, besides discussing the questionable benefit of ultrasound, I also discuss that when you have pain in multiple places, you want to put emphasis on strategies that benefit you more globally….that is one of several arguments I would make for exercise. I might have even picked out something else that she believes in that has a benefit for her whole body and give her positive reinforcement for that, like the anti-inflammatory diet (I would not go down the supplement road with her), while nudging her away from the ultrasound.
I would not use ultrasound unless there is a specific finding that I am treating (ex:
hypertonicity in a specific muscle, or other pertinent finding – I am sure she has plenty to offer). The other thing I do is use assess/reassess to help to compare the benefit of ultrasound versus other treatments. Often, the patient will ‘discover’ that other treatments are more beneficial from the reassess if I don’t directly tell them that I am rechecking a movement or test to test the benefit of the ultrasound. In other words, I reassess a movement after ultrasound, then after exercise, then discuss/compare the results, trying to avoid the placebo influence. I love it when you can turn these patients to trust your clinical reasoning by discussing your examination findings related to their complaints and using assess/reassess, rather than continuing to try to tell you what will make them better. Lastly, I do state my limit on the first or second visit. I tell them that I phase out ultrasound after 3-4 visits, stating whatever reason that I think will make the most sense to the patient.Hi all –
– In regards to clearing the differential list, besides neuro screening, any thoughts on quick clearing tests for the lumbar spine that would relate to her agg factors (hint, agg in upright activities which increase vertical load).
– Also, you discovered many important findings in your examination which may be associated factors to her pain, but it would be helpful if you can reproduce her pain to gain a better understanding of the structures involved and for better reassess for improvement with treatment. Based on her aggravating factors, what will likely be the ultimate functional tests to observe? Also, I am wondering if previous negative tests may be positive if tested after she has been running/jumping.
– In what ways do the subjects in this study differ from your patient?
Hi Katie – First, thank you for this interesting post. Second, I agree with the previous posts, that I would assess the ease of improving foot mechanics without an orthotic first. If the patient is having difficulty improving neutral foot with verbal cues and other techniques for neuromuscular re-education, I would use an orthotic (not hard plastic) to assist her in improving neutral foot position. You could use your functional squat test and maybe your thessaly to reassess with orthotics to help to determine if there is additional benefit with the orthotic.
In regards to her knee hyperextension in stand – I could not tell by your examination above whether there was hypomobility in the talo-crural joint and any limitation into ankle dorsiflexion, either due to joint hypomobility or muscle tightness. If there is restriction here, I would treat these impairments since this could be a strong associated factor to standing in knee hyperextension. PNF techniques are a great tool for improving control in weightbearing in terminal knee extension while avoiding hyperextension. You could use slow-reversal hold with manual contact proximal to the knee or rhythmic stabilization at the pelvis or shoulders while the patient maintains knee extension (w/o hyperextending) or in slight flexion. You could also have the patient do resisted upper quarter patterns while maintaining the desired knee position in weightbearing.
Jennifer – You have no doubt just posted a very important aspect of her care which will help optimize her results. However, I want to make a couple points. It is very helpful to get in the habit of asking on day 1, specifically, where pain is NOT and checking it off on your body chart. For her, I would have subjectively ‘cleared’ upper extremity symptoms and symptoms in the face and chest. THEN, when they walk in and tell you that they have tingling in the arms, you have a quick reference that you did in fact ask and they denied symptoms in these places. Now that she is describing tingling in the arms, you need to ask a specific pattern to help you with your clinical reasoning.
Now that her status/symptoms have changed, you have more in your clinical reasoning chart. Even if your neuro exam was negative previously, would you repeat? If you never did a neuro screen, would you do one now? What would you include in your exam? You mentioned in your presentation that you had done upper cervical instability testing. Which tests did you do and what was the outcome? This is a good time to be analytical about ANY influence, psychosocial AND otherwise, that may have contributed to the significant regression, then improvement in her symptoms.
Remember, even with strong psychosocial components, you often have musculoskeletal and neurological components that may be very significant…they may even be feeding the psychosocial aspect of their presentation. Make sure you clear potential yellow/red flags to ‘prove’ your hypothesis of their significance or lack of significance.
katie – Thanks for presenting this interesting case! I would not hesitate to refer this patient to a psychologist. It is an opportunity, really, to address likely ‘associated’ factors. I would approach it as being a very difficult life experience – she would benefit greatly from having a non-biased professional (not just family) help her through this and give her advise/strategies to help her manage.
I also agree w/ assessing/treating neurodynamics, as indicated.
Prognosis: I expect this to be prolonged process – I do not expect quick or huge changes on reassess and reassessing will be easy through all of the ways discussed during your presentation.
Treatment: In addition to all you mentioned, I would use A LOT of PNF principles/techniques with her. Specifically, you can use functional patterns which cross mid-line, using visual tracking during the pattern for repeated recognition of the affected limb. Also, you can treat her affected side indirectly by using full body patterns through the upper extremities to encourage work and weight shift to that lower extremity through a developmental progression (starting with supine, then to rolling, sitting, then PWB standing to FWB as tolerated. You can also use bilateral lower extremity patterns to facilitate overflow activity from un-affected to the affected side. If she can’t move through a full range of a pattern with the affected side, you can assist with the un-affected side, which will facilitate recognition and help her repeat normal functional patterns of movement w/ better tolerance. If she can actively move through a normal pattern but can’t tolerate resistance, add resistance on the unaffected side, again, for facilitation/overflow.
Again – I would use a ton of visual tracking of the affected limb during exercise.
Great discussion! A couple thoughts: I would not do a mid/low lumbar grade V with an intermittent foot drop. Remember, when discussing in relationship to previous manipulations by the Chiropractor, the presentation was different when being treated by the D.C. His symptoms have regressed.
Great points about considering adding treatment techniques for hypomobility at the hip and thoracic spine then reassess effect.
Treatment 3, please clarify your progression noted (8-10 minutes). 8-10 minutes of gapping in nerve tension position??
With running assessment/strategies, he seems to improve both with repeated extension and by running on an increased incline. Is this a consistent/expected pattern? What do you think is happening with the repeated extension vs. increasing incline which results in decreased symptoms?
In regards to communication w/ MD and/or referring out: I would first ask him if he told the MD about the foot drop and inquire about the MD’s neuro exam (to see if the MD is monitoring and will be monitoring his neurological status in the future). If the MD is not yet aware of the intermittent foot drop, I would call, tell him/her about his symptoms/clinical findings/history progression and let him/her know that I am monitoring the neuro/discuss together at what point we would recommend consult w/ a spine specialist MD. I would also discuss this with the pt., to determine the pt’s personal philosophy on seeing a spine specialist. Some feel comfortable with being monitored by their GP and PT, being referred if signs regress. Others, in light of his progression of symptoms over the past 3 years, want to establish a relationship w/ a specialist MD even if they don’t need any current intervention by an MD. Even though symptoms are not irritable, I would lean towards referral to a spine specialist MD due to the regression that has happened over the past 3 years with relative recent onset of foot drop. If he turns a corner and suddenly has a regression of neurological status, better to already have a specialist who he feels comfortable with with whom he can get seen on short notice. I would try to discuss what is in the patient’s best interest w/o elevating fear. However, the patient needs to understand that it is important to not delay in reaching out to a member of his medical team immediately if there is a progression of the foot drop.
Love the FOTO prediction – 1 point of change?
August – Thanks for presenting this interesting case! Some thoughts:
She seemed to live with this anomaly w/o symptoms until recently. First, be sure you verify this when you do your subjective – ask thoroughly about previous history of symptoms. If this is so, ,I think there is a reasonable chance you can get her symptom-free again. What I would really grill her on is what was different during the time the symptoms started. What was she doing that day? Anything different at work? Changes in life stress? Anything that promoted sustained postures that would contribute? This can help you in your identification of associated factors to onset which will help you with treatment choices in regards to education.
In your exam, because of the distribution of symptoms, I would have evaluated ULTT w/ ulnar and radial n. emphasis on day one or two. Efficient to do all 3 when you do one. In regards to adding nerve glides when I have concern about irritability, I start with a conservative prescription, maybe 10-20 reps, 1-2 x/day, educate on responses that should lead the patient to discontinue the exercise, and see the patient for reassessment/progression in a day or two, if I have a high level of concern.
Anxiety – In addition to the pain science influences, there are other influences. When under stress, you are less likely to exercise consistently, less likely to pay attention to posture, less likely to do your prescribed home exercise program. I am sure to point this out. I would have started the pain science education early on in treatment, assigning her to watch one of the videos we have discussed in previous discussion. I would recommend having her document a certain number of minutes of moderate activity per week, starting with 150 minutes based on the documented benefits to general health, then progress her to 300 minutes per week.
Progression of treatment – I am seeing some very effective treatments that get stopped on subsequent treatment when additional treatment. I would recommend leaving in techniques that you previously determined were effective if there is still an impairment to treat and layering in new techniques/reassessing their effect.
I love the construction worker’s boot example Scott!
I like to refer people to Lorimer Moseley’s Ted Talk, Why Things Hurt, which is also SO not on the 5th grade level, but I think patients get a lot from it and he is also so entertaining which I think makes patients more receptive to the concepts.
Falls history is one of the greatest predictors of falls and this is where the focus has been with the implementation of PQRS. I think the questioning for PQRS has been good because it has gotten P.T.’s in a better habit of asking about fall history. My observation is that we tend to do these tests When there is a history of falling or the patient presents with overt signs of impaired balance or strength. I have watched Physical Therapy become a doctoring profession and it is slowly becoming a profession that is focused more on community wellness and prevention. It would be great if we could get in the habit of using these tests to screen for early deficits and take steps to prevent the ‘fall history’. This could be a valuable (literally, by saving many medical dollars) part of an annual P.T. preventative physical.
August – Thanks for your post. I agree with your examples. Another good one.. lumbar extension exercises. I have seen many who started doing them after an injury when they were much younger, who continue to use them as their ‘go to’ at a later age, different MOI, etc. for minor episodes of low back pain without good results. Often, the episode is not bad enough to seek care, but they continue to be ineffective at self-treating until they land back in P.T. with more significant symptoms.
I agree about what you said about your experience with the PCP. Unfortunately, many influences in our current healthcare system have created a situation that is not at all ideal for having a collaborative relationship with our PCP. I have observed that patient’s who are members of concierge medical practices get much better ‘Person-Centered’ healthcare.
As far as dentists – I have learned much/collaborated much with my dentist and feel certain the preventative care I have received from my dentist has been successful at decreasing the magnitude of dental problems.
The benefit I see from seeing people 1-2 x/year on a preventative/educational basis is that you would catch problems when they are small. You can ask them about any small problems they are having and talk to them about their activities. You can then do a musculoskeletal screening examination that is specific to their lifestyle/activities/complaints, discuss preventative strategies/tweak their exercise program to target impairments, etc. Much like what I see with patients who come to P.T. under direct access when intervention happens sooner or when the problem is less complex, I would expect you would see the person less often for bigger problems if you can educate/collaborate on a preventative basis.
Great post Scott! As I read your discussion, PNF patterns and principles come to mind..(PNF is for orthopedic patients too!). I am going to contribute to the ‘discussion’, referencing your comments under #1 with a few pictures. Thoughts?
Thanks for sharing AJ. I have always appreciated the concept of patient-centered care, defined as:
Healthcare that is a partnership among practitioners, patients and their families (when appropriate) to ensure that decisions respect patient’s needs, wants, and preferences and that patients have the education and support they need to make decisions and participate in their own care. An important dimension of quality, patient centeredness encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient. IOM Agency for Health
I like how this article challenges us to evolve patient-centered care and SDM to person-centered decision making. The concepts in this article support a wellness model instead of an illness model. It may challenge us to first ask the person a more general question, like ‘how are you?’ before asking about pain and function. Often, much is learned by asking this question.
It also recognizes the reality of the illnesses/impairments/injuries as dynamic, not static, which I think is fantastic. One of my mentors used to routinely use the phrase ‘responding to emerging data’ when she would use clinical reasoning based on the patient’s changing presentation to change course in examination and treatment. I think, too often, in the medical world, a decision is made, then never considered again. There are many examples, but here is one: The prescribing of hormone replacement when it is for the sole purpose of post menopausal symptoms. Many women would only have symptoms for a few months, but stay on the medicine for years without discussing the risks or the continued benefit with their physicians or trying to wean off of the medications. Unfortunately, many patients do not feel like they have easy access to their medical providers in order to follow up and have an open line of communication as suggested in the article.
Can anyone think of some examples in physical therapy where recommendations/home exercises are prescribed, the patient is’discharged’, continues their current program/recommendations without any continued dialogue and the advice which was once helpful later has a negative influence?
One vision of the APTA is for P.T.’s to become providers, like dentists, where instead of ‘discharging’ patients, patients have a P.T. that they see 1-2 x/year for preventative screening/education, then treatment, as needed, for problems that arise. Do you think this idea is more consistent with an illness model or a wellness model? Do you think it would support person-centered decision-making? Do you think it would result in more P.T. visits by a given individual who would otherwise seek P.T. for an injury or fewer visits?