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August,
I had a similar pt, HS pitcher with throwing shoulder pain. I had inherited him from another PT. Classic signs of impingement: painful arc, pain w/ resisted ER, (+)HK, active impingement test, full can. When I first saw him and looked at his total arc ROM limitations, I was concerned about GIRD and he had some (+) tests for labrum pathology as well. I got him on teaching time and Aaron and I immediately screened lower quarter and trunk. He had some serious weakness in his glutes and could only hold a bird dog on one side opposite his throwing arm. We gave him some isolated glute strength and added some posterior chain and oblique sling motor control and his total arc ROM improved. We were also able to look at his pitching mechanics with the same guy Justin mentioned who treats a lot of pitchers. As it turns out, his lead leg (L leg) was stepping across his body to the R instead of straight down the mound. This created increased torque on his shoulder and strain on his RC to do the majority of the work. After looking at that on film and slowing it down for him, we gave him a window for stepping with therabands and had him practice high volume reps of just stepping. He was able to pitch the entire season without any more shoulder issues. In hindsight, it would have been really cool to get a speed reading pre and post on his throws.
Erik, i think justin is absolutely right about peeling away the onion layers, but I also don’t think you necessarily had blinders on. From the looks of it I think your eval was pretty thorough and you may not have even gotten (+) findings from radial head limitations had you assessed that day 1. I have had a couple mentoring patients that had things show up after a few visits that even Aaron can attest weren’t there on day 1. I think sometimes we have to treat one area in order to expose another. As Aaron would say in my feedback write ups, thats why we assess, treat and reassess, so we can have a constantly progressing list of aggs/impairments.
I had one lady that was involved in an MVA in which she was struck in by a vehicle while walking in a crosswalk. Primary injury was RC with cervical component and some distal UE symptoms. Long story short her aggs were reaching OH and HBB to strap bra, take care of hair, don/doff clothes, etc. Those gradually got better and we discovered that she was having difficulty with carrying groceries up the stairs. As strength improved her difficulty with carrying did not. As it turned out, she had some old/cold knee symptoms that were making it difficult to nav stairs. We added some strength training and knee mobility treatment and 3-4 weeks later she was able to carry multiple grocery bags up the stairs.
Like your case, I don’t think we had blinders on but we had to improve her shoulder to expose the knee.
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I have not treated or seen CRPS personally, so it has been quite a learning experience reading everyone’s thoughts and cases2.
I think the most important thing, which is kind of the backbone of what we do, is to listen, as everyone has already mentioned. In my experience, These kinds of patients have been to several health care visits and are overwhelmed with information and worries. As Justin said, if you can establish an outline of expectations for them to get a clearer picture of the plan that helps. I also had a CI during one of my clinical rotations who would pray with patients if they were accepting. I know that’s not everyone’s thing but if religion is important to them and you can establish a rapport that way, it can be a very valuable connection.3.
It’s hard to answer this without having experienced it but I think my gut reaction is similar to the above responses. I would try to be in contact rather early just to gather as much information as possible to establish the best POC, and then keep in touch depending on the patient’s progress.4.
I think it is certainly feasible that Tsp manipulation can influence the nervous system enough to at least open a window of opportunity with this population, assuming they can tolerate it. After a quick search, I didn’t see any articles that jump out right away that would discourage it. I think it would actually be more tolerable for CRPS in the LE compared to UEs just based on testing position alone, not directly contacting the LEs like you would with UEs.1)Any other exam techniques you would have performed?
I may have checked joint effusion just because of the recurrence of episodic pain. Especially if you found weakness in quad activation at any point. There are a few articles that demonstrate the reduction in quad strength and ground reaction forces with knee pain and joint effusion. That may be important for determining return to run status, so probably more beneficial at toward end of care.
Also due to back and knee pain, you could potentially check pelvic tilt during fwd bending if she is having reduced hip extension strength to determine gluteal motor control deficits. Possibly a source of her back pain over the years of higher activity. I have seen glute strength improvement with pelvic ant tilt mobilizations within 1-2 treatment sessions.2)Any other treatment you would provide?
I like the dynamic training to help your patient feel like she is performing her normal exercise routine.3)Does anyone have specific parameters they use for return to run/walk program?
I have used the JOSPT perspectives that Justin mentioned before but I rarely see this patient population. I had a CI who wrote up a return to running program that was based off intervals of running/walking for 30 days gradually increasing, wish I had kept a copy of that now!4)I have not used manipulation with this patient as of writing this. Articles describing the use of manipulation for pnts with knee conditions usually describe the benefits stemming from increased quad and gluteal activation reducing PFPS or improving pnts muscle activation following ACLR. How do you think this case varies from those presentations and how would you have you added lumbar intervention to treatments if at all?
I have not used thoracic or lumbar manips for knee pathologies but I can see the benefit from the neuromotor aspects from that article you posted. I better step my game up!1. My initial question would be about her activity level as a child. If she wasn’t moderately active I guess I can see how it went undiagnosed or untreated. I think “false joint” evidence is intriguing, but I wonder just how much activity that kind of thing can handle.
2. I would have looked more at functional testing. The OA findings are not a surprise with her history and the lumbar findings seem to coincide with having bad hip mechanics for that long. Obviously her body learned how to adapt so I would have looked more into the adaptations via functional screening and see what you can find. Also hip AROM and strength. I think there may be some info there to guide your treatment.
3. I know you probably did this, but I think more info regarding her functional activity or recreational hobbies to help with specific therex. Thats the only thing I would have included that wasnt described in your post.
Article questions
1. I think the treatment plan is quite generic and I did not see anything that discussed progressions. There has to be a ceiling effect on the benefit of 4-6 exercises of 3×10 reps that were performed only at home.2. I think they identify the benefits of pt/therapist interaction in their discussion as a point of possible error. They discredit other articles based on subjective reporting but then the prescribed therex program and adherence to it is based soley on subjective report.
3. I think Erik makes a great point about the pt specific treatment model and clinical applicability of a treatment program from this article. The MT skills are generic and performing 4 techniques plus 2 additional “most effective” techniques in only 30 mins is spreading things a bit thin.
4. Obviously pt body type has to be considered but, for the most part, I believe current evidence shows that US does not reach the tissue depth to have treatment effect on the hip joint. Erik, I have only used US in combination w/ tacking and stretching on an acute hamstring strain under the guidance/recommendation of a past CI. It was effective there for reducing pain to allow the pt to perform his exercises, but we only used it for the first 2-3 visits.
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I would be hesitant to manip lumbar based on worsening presentation and previous use in tx by chiro. I think the benefit of our manipulations is that we add some stability component after. Did you inquire as to the tx given from chiro and if exercise was also implemented?2.
I probably would have checked FABERs and hip derotation test and STM along nerve path. Aaron and I had a similar presentation in a pt with stenosis and found (+) gluteal tendinopathy tests that allowed us to incorporate some STM in that region with success.3.
I think I would treat and monitor. If no improvement then consider referral.4.
I think it is probably multifactorial. Seeing his relief with increased grade on TM, likely producing more fwd lean, I would be curious to see what his running posture was like initially and compare that to now. It is possible that he had a fwd leaning posture when running (maybe compensating for decreased hip ext/push off) which would relieve compression based on his stenotic presentation; then, after some tx, posture and hip ext improved which allowed him to run more erect, possibly eliciting some symptoms in extended positions.5.
My initial thoughts are obviously “moderation”, decreasing load, decreasing time in activity, intervals with self mobs like you already had him do.
The devil’s advocate in me looks at squats, deadlifts and biking as having flexion components that may be relieving to an extent. Aside from the compressive loading, maybe these aren’t so bad?… which brings my thought process back to “moderation”…6.
I have never thought to go that far away from ground zero but, based on some of the presentations this past weekend with neurodynamics and “neurophysiological cascade of events” brought about through gr V mobs, I think it holds some water.7.
I had a patient with cervical radic that had some progressive declines similar to this patient. Also had some unclear UMN signs that became progressively more clear. Started having some fatigable weakness. Aaron and I experimented with providing manual traction and retesting Myotomes in sustained traction and strength was 5/5. Maybe traction is a different direction to explore with your patient as well?Phase 3: Strengthen The Complex
Improve muscle and tendon’s ability to produce force and manage load.
1. Start with bilateral tendon strengthening in mid-range tendon positions (neutral/no DF) with slow, tempo controlled movements.
2. Concentrics first, maintaining slow, tempo control.
3. Progress to unilateral strength, maintain mid-range tendon positions (neutral/no DF)
4. Rest to full recovery between sets for optimal strength and safe loading in pain free positions.
5. Strength training on non-consecutive days for ample rest/recovery time2-3 sets x 15 reps -> 3-4 sets x 8-12 reps with increasing load based on pt response.
Bilateral Exercises -> progression
Squats on total gym -> leg press -> Squats w/ UE assist via hand rail/TRX straps -> free squats
Heel raise on total gym -> on leg press -> in standing w/ UE assist -> free heel raise
Prone hip ext -> bird dog -> deadlift/good morningsUnilateral exercises
SL squats on total gym -> SL leg press -> SL stand/DL sit
SL heel raise on total gym -> SL heel raise on leg press -> SL heel raise/DL return
Step up w/ UE assist -> step up -> step up w/ row for post chain activation
4 way steamboats on air -> against resistance
SL cone taps -> SL deadlift w/ KB/DB (Flamingos)
Fwd and bwd stepping lunges -> add resistance w/ KB/DB/barbellPhase 4 – Progress load
1. Progress from concentric to eccentric loading
2. Progress from mid-range to full range tendon position (past neutral into DF)
3. Start with bilateral and progress to unilateral exercises
4. Rest to full recovery b/n sets for optimal recovery/hypertrophy
5. Continue with strength training on non-consecutive days for ample rest/recovery
6. Heavy, slow resistance with controlled tempo
7. Progress from phase 3 increasing sets and decreasing reps with increased resistanceExercises from phase 3 can carry over with increasing ROM and focusing on eccentric phase of movements. As strength and tolerance improves, can begin to implement explosive concentric phase with controlled eccentric phase.
Additional exercises to consider:
Baps Board w/ weights for progression of foot/ankle control through stance phase
Lunge with high knee -> progress to include heel raise at end of concentric phase
step up row -> progress to include heel raise
KB swing in bilat stance w/ both UEs -> progress to tandem stance w/ 1 UEEducate patient on importance of compliance of 3-4x/week for proper rest/recovery to allow tissue healing, strength improvement and increased tolerance to load gradually prior to beginning return to run program through phase 5 and 6. Educate pt on the length of the strengthening phase, taking several weeks to months prior to tolerance to running.
1. I have never seen a patient with TOS so this was a very eye-opening case presentation. I don’t think I could have confidently been that thorough at the initial visit. How much of that did you get done on day 1?
2. Same as what Justin said, prior to VOMPTI class, I had been fine with giving glides or flossing on day 1 but I am less likely to do that now. As with everything else, discretion is the game we play. I think it is justifiable if you have some peripheral neurogenic symptoms but low severity and irritability and they have demonstrated quick on/off times.
4. I have struggled here because I have a hard time accepting that we dont have to have every answer on day 1. We have the benefit in our profession of multiple visits and constant reassessment so I think addressing what you can to show some improvement and then adding a piece in successive visits may be best, which is what it appears you did based on your progressing treatments at each visit.
5. I dont think I can answer this one without having been in that situation. I have taken notes from everyone’s perspectives above for future reference. For your particular case, I think this is similar to our pain science discussion in class on Sunday; there are so many ways to go. I think Eric’s analogy of “tossing out a little nugget” and seeing where it may lead is fitting and I like Justin’s approach of spinning it toward the positives. Maybe that discussion is a day’s treatment in itself, like Dhinu said, sometimes that conversation is more powerful treatment than being hands on that day.
I agree with you Scott, about not wanting a pt to lose faith but I think there are effective ways to spin it to get them back onboard (sailing pun??)
I learned from a conversation with a CI that a simple explanation is that, although we like to be evidence based, PT is often an art and not an exact science. what works for one may not work for another. The important part is that we made a change in the environment, even if it was a negative change, at least we now know that we have affected the correct tissues and we can devise a new strategy for making positive change. Good change or bad change is better than no change.
I have used that fairly successfully with my patients since then. Especially those who become greatly concerned at the first sign of failure.
I had a recent patient s/p RCR referred to us after failed PT at another local clinic. My pt reported that his dr was irate with this other clinic and had called to tell them he would never refer another pt there and that he was considering sueing them due to not following protocol and being too aggressive. He feared they had contributed to a retear. The script came with a complete protocol and instructions to begin at phase 3 for strengthening.
I was already terrified and thinking that I was going to have this dr breathing down my neck just waiting for me to screw up. I doubted myself before the objective exam even started. I found that this pt had TERRIBLE quality of motion and poor motor recruitment and in my opinion was not ready for strengthening.
I articulated that to my pt and explained as clear as possible in my note so the dr would hopefully understand. And I began working on ROM and movement patterns, with scapular motor control.
After my pt’s next follow up with the dr, he came back reporting that the dr was very impressed with my note and MY POC. He asked the patient to pick up a bunch of business cards so he could refer to us in the future.
What I learned from this is not that I am a great PT, but that I have been trained to see things and respond accordingly, and sometimes dr’s pay attention to that. I was nervous and thought about it for 2 weeks before I got that response from the pt/dr. I still struggle with confidence but I feel better about my decision making and trust myself more. I thought this story might be helpful for some of y’all if you feel the same way.