Forum Replies Created
-
Posts
-
Halley,
Thanks so much for sharing and posting. I must admit that this article was a little hard for to with the large proportion of statistics and how the measured agreement/accuracy. However, after spending a little bit of time with it I think I have a decent understanding of the results.
A few thoughts:
– Oksana – > the patients included in the study were those who had undergone standardized routine examination by a physician including the use of other imaging modalities; only patients deemed appropriate for arthroscopic investigation were included. That is, the ruling out of red flags had already occurred by the time the patient made it to the PT/arthroscopists, so that this study really can’t be used to help determine if we are/aren’t able to identify more serious red flags via our comprehensive clinical examination, though you are right to indicate that this certainly is important. I would like to think that if studied we would have better accuracy at determining mechanical vs. non mechanical shoulder pain.
– It certainly makes sense to me that we are better able to identify the structure at fault compared to the specific pathology of that structure. I think that this has larger clinical relevance as well. That is, my treatment approach differs more if my working hypothesis is glenohumeral hypermobility due to a passive constraint lesion than some form subacromial disorder in the absence of hypermobility, than it would if my hypothesis was supraspinatus tendinopathy compared to subacromial impingement.
– I don’t suppose myself to be a better therapist than any of the clinicians participating in this study; however I would be curious to know what elements were included in the standardized history and examination, and the diagnostic reasoning form that was used. Perhaps I missed it, however I did not see any reference to an appendix that might include such information. I would be interested to know how their examination and reasoning process compares to the one we utilize.
– “The finding of structural pathology at arthrosocopy does not necessarily mean that the pathology is the source of the participants presenting symptoms.” I think that is a highly relevant statement, one that must be considered when interpreting the results of the study. How would the results have differed if the MD diagnosis was made on the basis of both history and exam + arthroscopy results vs. arthroscopy alone?
– The final paragraph in the discussion prior to the limitations was most helpful to me. Two things in particular. First, in our examining and treating patients we must evaluate treat the entire patient and not just the pathoanatomics. Second, although identification of specific tissue pathology may help with safety and prognostic value in certain cases, our treatment is based heavily upon impairments identified contributing to functional limitations vs. tissue specific pathology.
Thanks so much for posting AJ. I was fortunate to have ready this article a few months prior to starting residency, however I gleaned even more from it this go round. A few quick thoughts I had while reading the article:
– Was surprised to see that surgery for stenosis was the most common reason for lumbar surgery in the U.S.
– I thought a real strength of the study was that all of the patients included were deemed surgical candidates. If PT was beneficial to patients even with this level of impairment and pain, how much moreso is it appropriate for those with less disability.
– Lumbar flexion exercises received a grade of C in the practice guidelines, but were a core intervention in this study. Several PT interventions were used, and there was no control group, however I wonder if this study will contribute to increasing the grade of recommendation when the guidelines are updated.
– “Of the 481 patients who met eligibility criteria, 312 declined to participate, with most preferring not to risk randomly being assigned to the non surgical group and instead going straight to surgery.” Did anyone else cringe when they read this? I am assuming it was made known to the patients that they could transfer over to the surgical group at any time during the study. If so, this statement is quite condemning to our cultures attitudes and beliefs regarding surgical vs. skilled non surgical care.
– Along the same lines as the above statement, a very large percentage switched from PT to surgery. Misguided and erroneous beliefs (lower education levels noted in this group of patients)….
– An ODI of 27 at 26 and 104 week follow up for patients who were deemed appropriate for surgical intervention seemed quite satisfactory to me….go PT.
Other thoughts?
Recognizing the psychological and erroneous belief components of patients pain in cases of chronic LBP is something I am growing in appreciating the importance of, and yet I still feel very ill-equipped to manage these patients. I am sure the next OMPTS will give us additional tools in helping work with these patients. I am also excited for Rusty Smith’s course in the spring on the biopsychosocial approach in managing patients with spinal instability.
I have yet to read it, however the O’Sullivan crew just published an article in PTJ on Cognitive Functional Therapy for Chronic Disabling Low Back Pain (see attached). I am sure it contains a lot of pearls. The appendix also looks to be especially helpful.
Great case Laura! I am impressed with the comprehensiveness of your exam, and certainly it is a very interesting case to discuss.
– I cannot recall ever treating anyone who had an onset of musculoskeletal symptoms following a sternotomy. I certainly have seen individuals post CABG, however have never found this procedure to contribute in some way to the patients pain. It certainly makes sense that it would lead to anterior muscle tightness and myofascial restrictions.
– Manual mobilizations to the T spine and ribs in the positions you mentioned might be difficult. However, I do think you have a fair bit of therex at your disposal if you think it might be appropriate. Seated retraction over a towel and sidelying open book stretch both fit the positional descriptions and might help to improve the mobility in the area. If he is okay with quadruped, you could also do a thoracic rotation exercise from that position as well. Here is another quadruped thoracic extension mobility exercise that I occasionally use with patients – also helps to stretch the latts: https://www.youtube.com/watch?v=qovO0ysEpuc
– I am supposing that cervical quadrant was negative bilaterally? Spurlings as well? Was the sustained cervical extension active or passive? If active, I might try and do it passively, then add distraction and see if his symptoms abate (what Sean said).
– As you seem to hint at by your last question, one of the main disadvantages I noted about the use of US was the patient positioning. In the STM group, the intervention was performed with the patient in a neurodynamically lengthened position; whereas in the US group the neural structures were on slack. I would be curious to know what, if any, treatment effect occurred from the mere 15 minutes of positioning in a nerve-tensioned positioned.
– I completely agree with your picking up on the inclusion criteria that might bias towards individuals who would benefit from STM (i.e., tender points in various muscles). However while I think this does add some bias to the inclusion criteria, in the end I am not sure how much it would have limited the patient population; that is, tender points are highly likely to be found in this group of patients. If you removed this from being part of the inclusion criteria, I doubt very many patients, if any at all, would have been removed from the study.
– Never seen T4 syndrome and can’t say I know anything about it. Might need to find a PDF…unless you have one at your disposal Sean?
Lots of good discussion…thanks everyone for really putting in the effort to make a thoughtful and thorough response.
I think that you made a great point, Laura, in that video tape analysis is very different from face to face patient examination that is a dynamic process. Certainly, the examination of these several different motor controls tasks is in its early stage. Hopefully we will see a more clinically based study in the coming years.
I also like the mention of including the mid/upper thoracic spine in the exercise prescription. A patient is certainly going to have a tough time controlling/moving into lower cervical extension if they are hyper-flexed in the mid to upper thoracic spine.
Great case example, Sean. In your case, the abnormal movement patterns/muscle dysfunctions in the cervical and thoracic spines contributed to this patients shoulder pain. I think it is equally likely (as you stated that the end), that this could work in the reverse as well – underlying and perhaps painless GH/scapular dysfunction contributing to altered and painful movement patterns in the C spine.