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Undoubtedly what stood out to me was the seemingly dominant volume of what NOT to do.
Specifically, we should NOT offer: routine imaging, belts or corsets, foot orthotics, rocker sole shoes, traction, ultrasound, PENS, TENS, IFC, paracetemol alone, opiods, anti-depressants, antivconvulsants, spinal injections, spinal fusion, and disc replacement.
Clearly the authors feel the need to put a halt to a lot of bad practice that must still be routinely occurring (else there would be no need to write a guideline telling us not to do these things).
While I recognize the preface of sorts that says the guideline is not law, and while I agree generally with most all their prohibitions, some of them seem quite strong and perhaps over-stated.
Can’t quote much research here, but it sure seems reasonable that an anti-depressant could be helpful as part of a multimodal approach for a patient who truly has signs of clinical depression. Perhaps the anti-depressant would help them be more willing to exercise or re-engage in typical activities that they had been avoiding as a side effect of the depression. A similar case could perhaps be made for some of the other prohibitions.
The people who wrote the guideline are much smarter than me, and I could probably count on one hand the number of times I have recommended what they specifically have said not to do (and thus I am in significant approval of the recommendation), nevertheless some aspects of their prohibition seem quite boldly stated.
Interesting article Sean, thanks for posting.
I have very limited exposure treating patients whose primary complaint was headaches. Thus, I cannot say that I have much interaction with patients who seemed unduly fearful of the experience of a headache.
I did treat one patient over the past year who seemed to suffer from classic cervicogenic headache, though it was chronic in nature. He seemed very reasonable and his symptoms seemed so blatantly mechanical, and so I never queried further regarding his fears or anxieties regarding his headaches. I would say his outcome was modest, but think that it could have possibly been improved if I had questioned him more in this area/provided further education on nervous system sensitivity that is responsible for perpetuating his symptoms.
There is no doubt that a takehome point from the entire residency and that we have discussed several times via journal club/on this board is that vernacular is huge. “Locked facet joint” sure doesn’t sound good. Definitely signals a need for an external agent (e.g., YOU the PT), to “unlock” it. Even a simple change from “locked” to “stiff” sounds and feels very different.
Thanks for posting this. I read this a few months back and almost wrote up my monthly research review on it. Botux for knee pain was certainly a new concept for me.
Your questions all point the right direction in my mind. The inclusion criteria is certainly VERY specific, and the good results may be from such specific criteria as the intervention is very pointedly directed towards the potential tissue at fault. What should be obvious is that we can’t take the results of this study and then say that botux into the TFL is the solution for everyone with PFP.
Modified ober test reproducing pain? Maybe I am doing the test wrong, but rarely is this test itself actually provocative. Have you guys found this test to be pain producing?
Again, MRI confirmation of injury is HIGHLY specific. How many of my patients with PFP would have grossly normal MRI (grossly normal meaning only findings that are present even in the vast majority of patients without pain)? >80%?
Your second question also went through my mind. I wonder if ihibitory soft tissue work to the TFL combined with exercise emphasizing glute med>TFL activation would have yielded similarly beneficial results? I Know the patients had prior PT – wonder if this was part of it. Do any of you routinely do manual work in attempts to inhibit TFL? Any results? I am sure many of us are working on glute med>TFL activation.
Why were symptoms improved for such a long period of time? Because of a highly specific impairment with a very tailored intervention followed by, “single leg strength and control work exercises.” No way botux injection alone is responsible for the improvement. No change in movement pattern and almost certainly the symptoms would have returned.
The authors found that botux into the TFL increased ober length. Interesting in light of this study where ITB was transected and resulted in no change in Ober length. #deadpeoplestudies
- This reply was modified 4 years ago by Nick Law.
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Laura – yes, exactly. The point of the article is to show that evidence AND clinical reasoning dictate clinical care, and therefore I think the title is misleading. It simply continues to suggest the notion that the two are in conflict.
Perhaps the evidence supported practice wheel really will be helpful to some, however to me I simply see nothing wrong or imbalanced or unhelpful about the three dimensioned nature of classic EBP – published evidence, clinical expertise, and patient values. I think that their diagram is simply trying to draw out several factors that I think are better left simply explained in written words than trying to diagram everything out.
To answer my own last question, I think it depends on who the therapist is. I think that newer therapists such as myself are prone to more heavily rely on the most recently published evidence, whereas more experienced therapists seem vulnerable to simply doing what they have always done/achieved good results with. We younger therapists would do well to learn when to simply trust our own experience and expertise even when contrary to recent evidence, nevertheless continuing to reference and examine our methods with the available published evidence.
I am very much in agreement with Sean’s pointing out the training errors contributing to this injury. Doing some mile repeats or something of the like would probably be fitting, however “sprints” certainly seems inappropriate if the goal is to run a marathon. Definitely smart to spot that and educate on appropriate and beneficial training.
I am not sure we can effectively, “rule out,” neurodynamics at this point; however, if reverse slump is negative and altering SLR straight leg raise with cervical flexion/ankle DF /hip ADD does not change his symptoms, I am not sure we can decisively rule it in at this point either. While a high percentage of patients have been shown to have neural mobility deficits with hamstring injuries, it is not all of them, and we do well not to bias ourselves into thinking something is there when clustering of tests are negative. All that to say: do some more neurodynamic testing as mentioned and treat what you find, not what you don’t find.
The picture certainly looks less grim with the rest of the physical exam presentation you provide, however I still can’t say that I wouldn’t have been fairly cautious and conservative based on the history.
I presume CT was performed in a neutral head position. Flexion/extension X rays can be used for C1/2 saggital instability. I am not sure they ever perform this, however I wonder if end range rotation X rays would be able to show more than a neutrally oriented X ray.
Oksana – if there is no pain with exercise performance, exercise technique is acceptable, it doesn’t excessively exacerbate symptoms over the next 24-36 hours, then I would probably feel good about continuing with lengthening exercises as you have done.
I agree with Laura on aspects of tendinopathy vs. muscle injury. In general, I think that tendon injury tends to take longer to recover from (though of course depends on severity of injuries you are comparing). I might tend to be even more movement-analysis and correction oriented with a tendon issue vs. a muscle injury. Repetitive loading in an poor fashion seems more to be the culprit in the former, compared to “simple” overexertion in the other.
Great point on lengthening exercises in “stretch” injury patients, Alex. I am working with such a patient right now and they have yet to prove effective. Also, thanks for posting the article regarding terminology and classification of muscle injuries – seems to speak some clarity into confusing terminology at times.
Thank you for posting! A couple of questions and thoughts:
– How long ago was the original injury? Antalgia with regular gait, inability to single leg squat, immediate pain with stair negotiation/resisted testing make me think that his injury is still fairly acute/subacute. In light of this, I would probably be cautious and stay away from eccentric or “lengthening” exercises in this stage of condition; that would seem to be too much load for the state his tissues seem to be in. Agility exercise, hip and trunk strengthening, manual therapy to prevent excessive scar immobility would certainly make sense to me. However, I know you have already tried the “diver” and so I am curious to hear how it went. Additionally, in this study they started such lengthening exercises 5 days after the initial injury, and noted that no exercise was allowed that caused pain. In my clinical experience those certainly seem at odds with each other, so I am not exactly sure how it worked out.
– Immediate pain with stairs, inability to perform single leg squat, and trying to run a marathon in 5 weeks seems like a very, very loft and likely unreasonable goal. I think you are very wise to give him specific time frames on how long it generally takes to recover from an injury such as his so that he can reform his expectations.
– I believe that the Askling H test is used to help make return to sport decisions late in the rehab process. That is, once SLR/resisted testing/functional movements are all WNL, THEN I would use the Askling active hamstring flexibility test.
– I wonder if “maxing out” on the last repetition of repeat sprints is not a good idea with regards to hamstring preservation. That looks like that may have been the mechanism in many of these athletes.
– I like the new article from Reiman on hamstring tendinopathy, however I would just be sure to draw attention that proximal hamstring tendinopathy and proximal hamstring strain are distinct conditions. I do think that there are a number of similarities in treatment approach, but I do think there is value in recognizing them as similar but distinct entities.
Thank you for posting this. I most certainly had not heard of Grisel’s syndrome prior to this post and the associated article.
As an aside, I think it is impressive and encouraging that you would have a mother want to bring their 8 year old child in with a potentially serious condition to get your input.
The child you are seeing seems to have a history and presentation that could certainly be consistent with a “lower grade” Grisel’s syndrome.
I would certainly be asking a whole host of questions and performing objective testing regarding neurologic symptoms, (cranial nerve, myelopathic signs/symptoms, etc…) as well as other upper cervical dysfunction/instability symptoms (e.g., headaches).
Although I would certainly want to get as much of the above information as possible, in light of the area of potential pathology and the risk of potentially serious consequences, I would proceed very cautiously regardless of what objective testing revealed and would advise imaging studies to be performed with potential immobilization for a defined period of time. I would probably advise against all activities that would place the child at risk for further instability progression.
My level of fear – as if this child has poor prognostic outcome – is not too high as from the information presented it seems she will recover well conservatively; however my level of concern and alertness would be very high due to the possibility of progression of symptoms and long-term consequences.
Aaron, I sincerely wish you had not asked that last question as that is what I myself was about to toss up to the board, as I am unsure as to the answer.
The authors of the attached article conclude that it is safe to adopt a wait and watch policy of cases of massive disc herniation if there is any early sign of clinical improvement. NO patients in the study had permanent motor loss; however, they did not examine/report the severity of initial motor loss and the rate at which it recovered. A descriptive study documenting the average time it takes for motor loss to return to normal would be well appreciated if it has not already been conducted.
I have no research to back this up, but my practice would be to give it at least 6 weeks before referring for orthopedic consult. That is, I would refer & probably continue to treat at the 6 week mark if there was absolutely no appreciable motor return.
Other ideas? How long would you wait?
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This is an interesting case; thanks for posting!
Seeing that his initial thoracic injury (and I am assuming his recent exacerbation at the chiro) occurred with rotation, have you examined how rotation effects his symptoms?
I certainly think it is interesting that T4 and T8 CPA increase symptoms but T5-7 did not.
As is always hard to ascertain with these board posts, what is this guys psychosocial profile? Kinesiophobia/catastrophizing/excessive perseveration on symptoms?
How does decreased reflexes, myotomal strength and dermatomal sensation affect your decision to implement neurodynamics? For me, the combination of all of these plus neural tension might make me slow to implement neurodynamic exercises. Especially if you are able to affect his neural tension addressing other components (e.g., T spine mobility).
My closing thought is that I would pay close attention to the neurogenic findings – dermatomes, myotomes, reflexes, neural tension. I sure think I would want to see an improvement in these over the course of time in a 25 year old male who had recent changes here. That may take a fair course of time, however I would hope and expect to see a trend of improvement.June 21, 2016 at 9:04 am in reply to: Functional Movement Screen ? predictive of Injury risk #3925
Thanks for posting the short critique on FMS Eric. As one who is not familiar with the variety of research there is on FMS, I feel more confident in understanding it’s limitations to date based on the research critique and summary presented in that article.
I feel more equipped at interpreting/handling some statistics than others – e.g, sensitivity/specificity, + and – LR vs. effect sizes, positive predictive value. Since working at UVA-HealthSouth and sharing some desk space with Kevin Cross (PhD researcher) I have come to appreciate more how statistics can be deceptively represented. We would probably all do well to review the presentation he gave at the beginning of the year.
AJ – thanks so much for posting, a good reminder of things that influence our outcomes beyond anatomy, biomechanics, and our manual therapy skills.
Laura – I do not frequently use mirrors, and seemingly never tell people do use them at home. I think that the use of mirrors really has to be patient-specific; sometimes I feel that patients who are put in front of a mirror become incredibly and detrimentally self conscious.
“The main predictors for male patients were the therapist and treatment outcome, whereas for female patients the most important elements were organization and the communication components of care.” This certainly confirms my own experience; we do well to recognize gender based differences.
“The formulation of a diagnosis…is a form of treatment per se.” I am certainly still learning how to give a detailed diagnosis, prognosis, and comprehensive explanation of the patients condition without rambling or speaking in terms or concepts unfamiliar to the patient.
Lots of good reminders and helpers in this article – thanks again for posting.
Also – I will be requesting a skylight for our clinic….for the patients sake.
June 9, 2016 at 4:46 pm in reply to: Functional Movement Screen ? predictive of Injury risk #3883
- This reply was modified 4 years, 1 month ago by Nick Law.
Based on reading the lit review in this study alone there seems to be conflicting evidence regarding the utility of FMS for prediction of injury.
My understanding: some people stay healthy because of their movement pattern, some people stay healthy despite their movement pattern, some people fail to stay healthy even in the presence of a good movement pattern.
My guess is that our ability to truly predict injuries will always remain relatively average at best. I hope not to sound pessimistic, but simply think that factors that contribute to injuries are too varied and complex and even unknown for us to have a high degree of confidence in predicting injury occurrence. I think we can be better than a blind guess, as even this study shows some relationship, I just don’t think it will ever be incredibly strong.
As opposed to merely predicting injury occurrence, I would imagine that we would have somewhat greater power preventing injury occurrence through specific training. I know we have some research regarding specific movement training and reduced ACL injury occurrence; does anyone know of other studies examining movement retraining and other injuries (e.g., PFP, ankle sprain, back/neck pain, labral injury)?
First, I would like to say that I completely agree and resonate with your comments at the end regarding our communication with the patient; notably, if we seem hesitant in providing answers to the patients prognostic questions then we may quickly lose their trust in favor of the MD who quickly gives a straight forward answer. However, while I think that the surgeons have a routinely confident answer to give, I would be sure not to confuse confidence with accuracy.
Prognostic questions/comparisons between conservative and surgical care can certainly be difficult at times. I am sure like most of us, I try to provide answers based on best available evidence as well as treatment experience. I also think that patient preference and personal factors /goals play a significant role.
Based on the research Eric presented in the course series as well as the patients seemingly low goals, I would confidently recommend to this patient a trial of non operative management. I would be slow to make any unqualified promises to the patient, however I would certainly sell at least a short period of non operative management to see if ROM, strength, and function will appear to be adequately regained. Being a male under the age of 30 are prognostically unfavorable, however he isn’t 18 either and his goals seem very modest.
A couple of questions that might influence me in thinking about this patient: does he have signs of systemic laxity? Also, perhaps more information behind his history of right shoulder injury and subsequent surgery, as well as how that shoulder is now functioning post operatively would certainly be valuable information as well.
- This reply was modified 4 years, 2 months ago by Nick Law.