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I wonder how his search strategy would change if he used the narrow and extended search strategy we learned. Granit our search is very manual based and the author’s PICO is TherEx based. I appreciated the Cochrane review as it focused on his PICO question. He also mentions using high quality evidence with a greater reduction in pain at the end of treatment and long-term follow up. Which is interesting why he used a 9 month treatment approach if the high quality studies went to 6 months? Nick brings up a good point that 4 sessions over 9 months, sounds like a very minimal dosage approach. As well, his literature review: the oldest study was published in 1991 otherwise everything else was >2000.
I would like to further look into different adherence strategies applied per patient. I know motivation is thoroughly important. As well, for her subjective information I did not see if she had any help at home? I appreciate how patient centered this review was and it sounds like she made great improvements over a short amount of sessions!
Thanks for sharing Alex!
I’m having a hard time finding the difference between a prescriptively selected (PS) treatments as compared to a therapist- selected treatment approach. Just to make sure I’m understanding this correctly group 1 (PS) received central PAs or UPAs grade III and the L4/L5 segment. Group 2 was the therapist selected group where they used a grade IV mobilization based on their clinical reasoning on the specified direction needed.
I find myself still struggling to find that specific segment that sometimes I’m lost in my own mind while I could be asking the patient how they’re doing. It seems to me that a PA at the L4/L5 area for patients with mechanical back pain have similar results as compared to the clinical reasoning behind therapist selected mobilizations. Something that stuck out to me was when Kyle shared at our previous conference in Winchester “patients will get better, but if you want them to get that extra 10-15% then that’s where specificity kicks in. Research hasn’t measured that extra benefit for patients. ” (paraphrased but meaningful) I believe confidence and competence of the therapist giving the treatments is pretty important. Maybe that’s what the results don’t know why at 6 months were better for the therapist guided group. For my practice, I want to be confident in what I do. Even if I don’t get that specific segment then I know I’m doing some sort of a difference that’s not contraindicated for the patient.
Subjects where recruited through advertisements, word of mouth, and via e-mail. If patients are taking time for this study, then hopefully they want to be there therefore this may have had a positive influence on the results. I have a patient who has had chronic low back pain, severely depressed, and the only reason he’s here today is because I treated his parents and they’re forcing him. GREAT! Biopsychosocial factors are totally not in my favor. One of the biggest things I’m trying to communicate is finding an activity that he finds some enjoyment doing. He said grappling but he’s afraid. Grappling is pretty aggressive (he liked pinning and throwing people on the floor) so we tried to talk through other less aggressive activities like maybe swimming. Looking back I should have probably said taekwondo? I would love anyones thoughts.
It seems to me that most of our treatments are tailored to how the patient “feels”. If it’s body image with their pelvic alignment then I try to focus on an impairment and see if the patient’s reassessment changes. Adam’s article focuses on the power of listening to our patients. I find this extremely difficult especially if the patient is a talker. My question is how do we better facilitate conversations at least during the evaluation? I agree with Myra when it comes to reassessment because patients need to see a change not only for a buy in but also for relief either that me physical, mental or both. Then again what sets us different then chiropractors? They do manual work as well. I don’t know if they reassess but some patients do feel better after and sometimes it stays the same or they get better. I definitely say that having the knowledge behind why we choose a technique gives us a higher probability of creating a positive change.
I agree with Bialosky: stay away from contraindications and apply your skill based on your clinical reasoning. If manual therapy worked 100% of the time then we wouldn’t have people arguing against it. Obviously there’s skill through confidence and we see our patients for 30-60 min per session. What they do outside the clinic is not our responsibility. Life is life and people will continue to live it how they please.
Education is definitely a theme! I try to use words of “this is irritating causing a muscular response” or to support manual therapy I say “Have you ever touched something hot and then grabbed your finger and rubbed it?” I don’t explain the science behind hypersensitizing receptors but I explain how manual therapy is beneficial. Going back to reassessments, I use this as a HUGE learning tool. Those who say “my arm is the issue” I show them how I move their neck and that reproduces THEIR symptom. I try so hard to find some comparable sign (my hope it’s the primary) in each treatment. Those who are the pro athletes make it challenging but I have to stress that tissue somehow or else why are they here? I still have difficulty finding the ideal comparable sign. What do you do when you can’t find that one thing causing their pain? As well, we see patients after plenty of other treatments and I ask them to explain to me what their pelvic alignment means to them? If it doesn’t make sense to them then I take the route of Alex and explain the “teamwork” approach for the body to work as a whole.
Moral of the story: Listen, educate, find a comparable sign, reassess, move what is stiff, decreased hypertonic tissue, and listen/ educate again. Of course using clinical reasoning and getting creative is part of the fun.
I would definitely agree with fully ruling out cervical myelopathy: 1) gait deviation, 2) + Hoffman, 3) inverted supinator sign, 4) + Babinski test 5) age >45 yo. (I had to review them for my sake) It’s good that you checked other UMN tests just to lessen the muddy waters.
Having a stability program for patient with spondylolisthesis sounds like a solid plan. However, tailoring a program for the patient is vital. They maybe uniformed treatment per patient to see the effectiveness of this particular stability program. For example, the bridging exercise might be aggravating for a patient like yours due to her extension sensitivity which I would cue her to extend from her hips without lumbar extension (common mistake that I see with my patients).
Having treatment once a month does not seem frequent enough. I’m sure patient’s form could be faulty and I would definitely encourage seeing them more frequently. As well, 15 patients dropped out due to various reasons. I’m sure motivation probably dwindled as time went on. However, just getting the person moving is better than “bed rest” which is why I can perceive positive results. It might be more helpful if this study had a comparison group.
Great case Laura!
During the observation you said SL stance on her L increased her lateral thigh pain. Did the pain radiated down to her lateral leg? Turning in bed brings on her B electric feeling, does it matter if she turns from supine to side-lying or side-lying to supine? What was her resting position? As well, when she was standing did you try to correct her posture (decreased lumbar lordosis) and see if that made a difference?How would you list her irritability level? If patients are low, I like to perform the vertical compression test (very slight gradual pressure) and show her where she buckles, correct it and redo the test. It has been a great patient buy in for me.
I would first consult with a coworker about the + Hoffman finding and if we had similar findings then I would like to follow up with her/the neurologist after the appointment.
Deciding a plan of care has always been a challenge for me. I would see how she would respond to her HEP and consult with the neurologist if there were any abnormal findings.
I do like the 1/2 foam roll! I assume it helps assist thoracic extension and posterior tilting of the scapulae during elevation with less influence of gravity! I do not have a incline bench at work, but I’ll try to rig something up with the treatment table.
Motor sequencing is something I’m trying to learn better. As Nick said earlier the brain will do anything it can to get a limb from point A to point B. One exercise that I have found to be helpful is having a patient in sitting with scapular retraction, thoracic rotation and cervical rotation. It may seem simple but I want patients to feel what’s moving and when it’s moving. Once patients can control these motions I try to progress from there. Once again keeping the patient’s goals in mind and progressing towards that direction is something that I try to be aware of instead of my goals.
If the patient is weak I’ll have them in sidelying scaption on a ball while assisting scapular glide. Then progress eventually to standing Ys against the wall and standing scaption. If the patient has a reactive pec minor then I try to decrease tone hoping that will help with movement. I’ve found that decreasing excessive tone and then progressing with movement has been helpful.
Sean- I also a lot of quadraped and “push to your heels and bring yourself back up” cues. I’m not sure what’s really being inhibited and articles such as what you provided are helpful.
Nick- The excessive elevation drive me crazy which is why I go to sidelying scaption/ elevation while supported on a ball. Have you found anything else that has been helpful to decreased the excessive elevation?Thanks for sharing Nick!
What was your patient’s irritability level? You mentioned that you did a right posterior quadrant test and you were able to reproduce her symptoms. Have you found that reproducing a patients symptoms early on skews following test results? If so how do you go forward in choosing the best objective exams? As well, any particular reason you used the supine thoracic manipulation as a treatment?
Something that I’m finding is how patient expectations influence motivation. As well, finding a comparable sign is crucial. I had a similar case and educated my patient how his neck was causing his shoulder burning pain. I told the patient to work through his exercises and he will see a change, surgery was not necessary.
He agreed to work through his HEP and by session 3 he had improved cervical AROM and decreased shoulder symptoms. If I’m able to reassess the comparable and make a change in function/ symptoms, then I try to use that information as an educational tool.I just checked out several of Dr. Evan’s videos, it’s great! We constantly play videos in our clinic. I have patients who would ask me questions about those videos and it’s a great conversation piece. I do have a problem with open ended questions, I feel as though it opens up a can of worms. I’m trying to learn how to best facilitate conversations within a time frame. I like how Dr. Hall emphasizes listening to the patient and affirming their courage to share information. I’m constantly affirming patients, partially because I’m optimistic. I also see the importance of summarizing what the patient said to make sure both the patient and PT are on the same page.
If a patient has high fear with any movement then I think it would be important to introduce the video Eric showed or the pain science one. I also think it’s important to compliment the video with support groups. We’re involved with multiple fitness centers around our area and we encourage people to come. Community is important.
This is great! Where do you find these videos? I wish I showed this to my patient last night. I can’t wait to share this with her!
Great question- I use the severity/ irritability scale on those patients. I see what’s important for them and/or how that limits their functional performance. I first think about common pathologies that I could see ie: shoulder impingement from bench pressing, scapular dyskinesia with assist; knee: PFPS (potentially due to imbalance to ABD and ADD). I make sure I gather some subjective and objective data. Education is key.
It makes since a guy who is stationary and then works out hard presents with spasms. I would first check out his MOI, postural habits, typical routines, and educate him about stability exercises while he’s at work. I would also find out his warm up/ cool down technique. As well, I know magnesium glycinate in right dose is great for calming down spasms.
It’s interesting how many docs take the “wait and see” approach. A potential reason could be to see if medication work. As well, the mentality of resting is important when it comes to healing a sprained ankle or wrist. When it comes to the spine, we are constantly using postural muscles. Staying away from lifting/ aggravating factors are important. I feel it is necessary to educate physicians on the importance of movement patterns and maladaptive behaviors. It was interesting how “more than 70% of cases with low back pain only needed 1 PT visit and less than 3% of the referred LBP patients required referral to an orthopaedic specialist”.
I agree with Laura when she talks about the limitations in specificity through some literature. I think it is important to classify patients with acute low back pain into specific categories because we know the classification method has had great results in outcomes.
There are so many barriers when it comes to early referral for physical therapy. People are just now realizing the use of direct access. Educating the population/ our patients on direct access and early PT is key. We need to show them how compensation patterns potentially could lead to more injury. We’ve done fitness screens at local fitness centers and we ended up getting several direct access patients.
I would love to see an article published on what LB pathology/ signs and symptoms would be perfect for early PT. I had a patient from a previous rotation who slept wrong. After analyzing movement, I found that she had a hypomobile segment. She fit the criteria for a lumbar manip. Post manip she was back to normal and felt great. I talked about a POC and the importance of exercise. She was satisfied and saw no need for more appointments. Since then, I never heard back from her.