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Thanks Nick!
EBP should help guide care but not necessarily dictate care. I love how this article places emphasis on integrating EBP and biopsychosocial factors. I don’t think there should be an “or” in the title; however, it grabbed my attention.
One of the many things that I appreciate about our practice is that anatomy will always be anatomy. There will be anomalies but it’s up to PTs to see if that’s relevant to our patient’s impairments, participation, and/ or function. One of my ortho professors always said KNOW kinesiology and anatomy it doesn’t change but research does. I’m been in clinics where a PT quoted cx extension is bad due to increased osteophytes based on some research article he read years ago. I disagreed. There are also PTs who will only do exercises that research deemed highly appropriate even though the patient just can’t do. If a patient is given an exercise then asking the patient “where do you feel it” is important. Athletes have thrown me off a ton of times; they are the best compensators I know. It’s important to know anatomy, give appropriate exercises, and make sure the patient feels what we are targeting.
Research gives us ideas and I think more clinics could benefit from it. It’s a balance! I’m not the biggest fan of meta-analyses because of the inconclusiveness. However, they do a great job of complying evidence. I don’t always look at the conclusion but the RTCs may have some good information.
Great case Laura!
Why was your secondary hypotheses is a disc protrusion? Initially you said a fetal position was relieving. However, thoracic flexion did reproduce his pain. It is odd that a T4 CPA would reproduce the posterior/ lateral calf pain. Did his hypomobile L4/L5 reproduce his pain as well?Due to this patient’s response to increased neural tension I would stay away from putting tension in his neural system. He seems to have a positive response to gapping techniques. I see you did the SLR as a re-assessment, I would also retest myotomes, dermatomes, and reflexes before giving a prognoses for sensation return.
Has he had any imaging done? I wonder why his symptoms started 6 weeks prior. Do you know if he increased his running and on what terrain? Have you tested his L5/S1 mobility and hip extension? A lack of hip extension might be a contributing factor on top of neural tension, hypomobilities, myotomal/ dermatomal limitations, and of course T4 syndrome.
Since he has been to the chiropractor and a grade 5 was not beneficial, I would stay away from it in the beginning. He has had a great response to thoracic mobilizations, and I believe it might be beneficial down the road.
How is his current right LE numbness and tingling sensation? I would love to recheck that post thoracic PA or have him walk up stairs.
Thanks for the case Sean.
It’s tough when a surgeon states a patient needs surgery. I would first consider the fact of how much gain we’ve had in just one treatment. If the patient has 12 more visits left there could be much more gain that is if he continues to work through his exercises and stays away from aggravating factors.
I would also exaggerate all the positive findings we had such as no irritation during his manual muscle testing. Yes, the patient does have a labral tear but because of his goals returning to ADLs and running, it’s highly likely conservative care is promising. Swimming may be more challenging but possible. Now, if the patient wanted to get back to competitive triathlons or extreme sports then we would have to consider other options. I would say PTs are very goal oriented and surgeons are very outcome orientated. Regardless of what I think, the patient is the one who makes the decision. I agree with Laura, sitting down and talking through the pros and cons.
I found it interesting that age was the most reliable factor for predicting recurrent dislocations. I would have thought the activity level would have played a larger role. I also wonder why he has had chronic right shoulder dislocations?
Your articles point out neurodynamic mobilizations. Which particular neurodynamic technique did you have the most positive result?
Education: I try to make an explanation as simple as possible. His irritation is L extension quadrant and I would show that motion on a skeleton and tell him how that irritates the nerve. I wouldn’t say anything about double crush because that sounds intimidating.
After the Grade 3 R SL flexion PPIVM, did that improve his left extension quadrant? If so, I would use that as an educational tool saying we can make a difference and we want to find what specific exercises would be best to tailor his presentation. Since his symptoms improved I might transition to a femoral nerve glide and see how his system responds?
I think evidence is great as it helps shape practice. I try to use it “judiciously”. If we see something that looks like it will help our patient then I say let’s try it. The case report you choose might help guide your treatment based on similar subjective and objective findings. I try not to disregard evidence if my patient does not fit all the inclusion or exclusion or if it’s expert opinion. There was very limited evidence for one of my patients with morton’s neuroma. He was not a success story and I worked hard working to address the impairments. I reviewed EBP, talked to my colleagues, listened to my patient (only wanted plantar soft tissue), and left his surgeon messages. I think it’s great to have some sort of resource to go to. I can’t fix everyone, but at least I tried and didn’t give up.