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I like these questions.
It all depends on the person in front of me. I follow the typical schema of any subjective exam so I typically ask questions during the aggs portion of my exam like are there other things that make their pain worse like weather, not sleeping, and stress. Likewise with goals, I tend to ask those questions about fear or missing out on social things here. Sometimes the functional questionnaire has picked up on this so it opens up a venue to talk about it.
During the wrap up portion if I feel i’ve built good rapport, I’ll ask them if anyone has every explained why they are in pain for such a long period of time (if they are a persistent pain patient). Usually this opens up a good window to do some pain science education and give them a nugget to keep coming back.
SNAG Article Questions:
– To find these articles, I use the following search string: “manual therapy AND cervicogenic headache AND cervicogenic dizziness”. Would you change anything regarding this search strategy?
I think it all depends on what you find and if it was applicable to your patient. Like Helen said, if you found a good mix of articles and were able to skim through titles and abstracts to find what you needed, your search terms were successful.
– Before reading this article, what were your views regarding SNAGs? After reading this article, has your opinion regarding this technique changed?
I’ve used SNAGs for a variety of patients and found them beneficial for improving cervical rotation. I feel like this article only made me feel more comfortable in suggesting it as an exercises due to being efficient and easy for pt’s to do to themselves.
– What do you make of the authors’ findings? And are there any glaring limitations?
I didn’t see anything — looks like a solid paper. I find it interesting that they did a follow up at one year and the people in the placebo group didn’t get better. I think 12 months is a pretty long time to have sought other treatment or tried something new. Those people participated in this study and just did nothing else for a whole year? And if they did try other treatments, it was the missing application of the SNAG that prevented them from better health? I’m not sure what to do with that thought.
Many of my patients with a little bit of leading questions for self-discovery can make a strong relationship between their symptoms and stress, but I do a poor job of then leveraging that to show them techniques to reduce their stress. I think I avoid it because what we tend to offer is meditation, breathing exercises, and things that can come across as hokey.
I’ve seen Anetta use what she calls “spinal decompression” with breathing for a certain count (in for four, hold for 6, and release for 8 or something another). I liked this approach because it’s nothing more than mediation and focusing on being present but presenting it within biomechanical language and linked to the pt’s main complain (their back pain).
Something to the effect of: “I’m seeing Mr. Smith and during our examination, we were able to rule out radicular pain or other musculoskeletal diagnoses. His onset of pain seems to be correlated with his recent change in statin medication. I’m concerned his symptoms may be an adverse side effect. Would a change in medication be a reasonable intervention at this time?”
I really like this script.
I, too, found the paper detailed but was thinking are there any resources (school or elsewhere) that you guys know of that highlight the most salient medications we should know about? Beta blockers for HR and Statins for myopathy are the two that come to mind, but I’m sure there are a core few that are the most important for us to know.
I think this is a better way to phrase goals around pain. Having the pt report that their pain is tolerable is way more meaningful than me just writing some arbitrary goal of having <3/10 pain or whatever.
I don’t know how you guys use a pain scale, but for me it only consistently comes up for evals, PN, and discharges for documentation purposes. Since it is on our intake forms, I use it more for insight into the pt’s perception, relationship, and understanding to their pain. It’s just one blip of many on the radar to make a bigger picture. So many people fill it out wrong (“Worst pain is 5/10 but on Average it’s a 9/10” or “My average, best, and worst pain is a constant 5/10 but it goes up and down with these aggs or eases”) so I find it more useful to frame discussions around things that come up.
For instance, does the outcome measure match the pain listed? If someone is stating 9/10 pain, but the Qdash is <20%, then that is an opportunity to discuss the pt’s experience to get a better understanding of their interpretation.
How do you guys use NPRS? I would be terrified to try and and use that as assess/treat/reassess parameter since it is so subjective. I always try and tie my pain reduction interventions with active/passive/functional/palpation/MMT/SOMETHING to make it more concrete.
Social media should be the great equalizer where the best and most impactful studies get filtered to the top, and we reward people in academia who are really moving us forward.
However, social media “influencers” within physical therapy do the same thing everyone else does: it’s about branding, imaging, creating buzz, and building an echo chamber.
There is a person I work with who has a podcast and an online platform who I’ve had discussions with previously. He is of the thought that everything we do is either a placebo or nocebo. Manual therapy isn’t directly affecting a tissue or system, it’s about the person’s belief. Everything is a non-specific input.
After looking at his cohort of people he interacts with online, I can see where this is all coming from. Instagram is filled with a lot of “manual therapy sucks” people. These folks cherry pick which studies they present so they can appear as cutting edge, open, and trendy. They create caricatures of manual therapists and then project how superior they are by defeating strawman arguments that no one actually holds.
It’s a shame really. (As a disclaimer, I don’t think this guy is doing this, but a helluva lot of people near him are).
So when it comes to this article and looking at social media impact, I’m not sure we should go down this route and hold that up high as a good thing. Social media is for hype and attention which certain topics and articles are better at creating. I don’t think we should necessarily reward the bad behavior I see happening online. Just going by rote numbers might be misleading of what’s actually happening, but I”m not sure how else you would track it unless you chose certain accounts and sources as the “reliable” sources.
1) How do you all narrow down your results to pick your final article?
Write a solid PICO that naturally narrows down the field then play around with search words to find a reasonable enough amount of titles (50 – 100) to scan until I find a a title that really grabs my attention. That usually gets me 5 -10 solid articles where I read the abstract and then decide which one to actually read.
2) What do you think about the experimental and control groups? Do the interventions seem to be adequate and functional?
At first glance, all of it seems super non-specific and general. I think Steven makes good points that the delivery of care in the experiment groups is probably more hands on and more involved and might deliver more positive perceived benefits of care. Clinical reasoning also seems absent from all of it. And of course it’s not functional, but like Taylor said, almost all “lumbar stability” exercises fit in that box.
3) Do you think that this outcome measure has any significance clinically?
With what we know about non-specific LBP, I have a hard time using this one finding and having it move the needle in clinic. One, I have no way to measure EMG so I couldn’t use it as a goal, but I’m not sold that this is the reason that they improved.
4) Any other general opinions on the article?
This is kind of a throwback study that hearkens back to the local vs. global core stabilization debate and the best way to get that TA firing. From what we know now about the multifactorial cause of back pain, it seems like it lacks the breadth of possible impairments and inputs for addressing LBP — reading it felt like I was going backwards in time.
I actually use special tests as objective *’s frequently. While Hawkins-kennedy is a “junk” test, it is useful when it recreates the pt’s symptoms. If we then improve the HK, then I feel more confident that we treated the appropriate tissues to have less symptoms with other tasks. Per what we talked about on zoom, I look at a lot of different objective *’s from different systems (something active, something resistant, something ROM, something that’s a special test) when it’s time for reassessment. This drives what interventions I proceed with next when I see what does/doesn’t improve. This, of course, fits well into a Maitland/pain provocation model where identifying the structure at fault can sometimes be less relevant…
…however, I think there is benefit from being as specific as possible and I think special tests do add some relevance. The author is being a bit ridiculous. Yes, multiple muscles probably contract during a full can, however how many of those muscles are clinically relevant? What do we know from biomechanics/anatomy to identify the most probable tissue at fault? Does our APR and palpation reflect that assumption?
Or just manipulate the thoracic spine.
Don’t give away all the secrets Eric!
As far as clusters of tests, I really like to see for a RTC tendinopathy: ER in different positions of length and location; Full Can in different positions; and (+) TTP to the supraspinatus. I’m not sure if you did those two tests during your exam, but it looks like ER wasn’t that positive, but did you play with it (put it in more lengthened and challenging positions?)
For instance, when I see her resisted abduction being positive, I wonder what her Full Can in abduction would look like and whether a Scap Assist test would help that or not. Then that leads me to looking into scap position, mobility, and MMT of periscapular muscles to build a case to treat that.
As far as labral, I always find that trickier. It seems like you have a fair cluster of anterior instability tests to say that’s what’s going on, but does that fit what her A/PROM looks like? Does she have lots of movement in some directions? Did her ER 90/90 go for days?
1) Like everyone else here, the nerve entrapments with typical signs and symptoms was super helpful. Definitely something I’m going to review and get more comfortable with so I can start being better at differential diagnosis with people with foot/ankle pain.
2) I have treated one runner at PRO. Having the simple screening tools that are intuitive for analyzing gait and return to running was super useful and something I can easily have on file and integrate when the time is ready.
3) I liked the Nerve Hydrodissection — particularly the pictures. I feel more competent in understanding the procedure and what a physician would be thinking when choosing to perform.
Differentials:
– Shoulder Primary Impingement, RTC tendinopathy/tear, labral tear, infraspinatus referral, frozen shoulder.
– Cervical Radiculopathy C5/6
– Lateral Epicondylagia
– Radial Nerve Entrapment at spiral grooveSubjective:
– clarification on radiating from elbow up.
– symptoms with head turns while driving, reading, computer use.
– has it felt like it was about to dislocate when reaching overhead?
– previous history of shoulder problems.
– Steven’s questions on position of arm during bump.Objective:
– Cervical Screen with Spurling’s and Back L quadrant to rule out cervical radiculopathy.
– Shoulder with the specifics of looking for painful arc, SAT, SRT, palpation to supraspinatus, ER and Full Can MMT, HK, GH IR limited/painful, Horizontal Adduction limited/painful, Hand behind back limited/painful.
– ULTT1 or 2b to rule out ND.
– Resisted wrist Extension TTP CET to rule out Lateral Epicondylagia.Anna:
I didn’t know it was a problem until I started talking about discharge. I started building my case by talking outloud my thoughts over a session (your ODI improved to this; you are reporting this; you are no longer reporting this and this). Then, I used this as a segue into discussing discharge planning and her readiness to take this thing on herself.
That’s when she gave me push back about the tight spot in her back. To her, this was where all of her pain was coming from, and she thought until it got “less tight,” she would never be normal. She wanted to be 100% normal, and in some ways, conceptualized this tight spot in her back as something the other reckless driver did to her.
The way I approached this was being 100% open about what I meant about this spot being tight and clarifying what that meant to me. I explained that this tight spot might have been there for years, and given her history of back pain, most likely was. I then further explained the sequela of events and how we can’t pin this on the other driver. Yes they were reckless and this really threw your for a loop, but we can’t necessarily pin anything I find with my hands on them given the time piece. Then, I discussed what does it mean to have a “tight” spot in the back and whether that is a big piece of the puzzle or not.
I did this because we had great rapport (she brought me a Sound of Music DVD and some Baklava) and felt comfortable expressing my thoughts to her. However, she didn’t accept this fully right away; I had to change my treatment style over the next 4-6 visits. I started to wean her off manual. I focused less on the spot on her back and more on movement. Overtime, she let it go, too.
It was a tough situation given the contextual factors of it being from a car accident.
I think hypervigiliance is a tough one. I feel like implying that we ignore their pain leads to the idea that they just have to learn how to “live with it” which isn’t the message we are actually sending. For me it’s particularly tough because I always screw up and ask them how they are feeling after interventions out of habit.
Not that this is a success story, but I am currently working with someone in their 70s with chronic pain, body chart 80% colored in kind of deal. They fell on their knee 6 months ago and fractured their patella. Their entire R LE now has allodynia and lots of pain which was her primary complaint, but if you got her talking, she would talk about her entire body and how it’s been that way for 40 or 50 years.
I’ve been performing desensitization techniques, pain science education, and just general movement to some success. However, during any intervention she was more than willing to tell me every little thing she felt, particularly during glute bridges. Thankfully, her pain kept moving around during this intervention (it was in her buttock, then her hamstring, then her core, then on the front, then her ankle).
I was able to use this as a springboard to tie in what we had talked about with pain science and check her understanding. I would ask her what she felt the reasonable explanation was for why her symptoms moved around so much and often times she would say she didn’t know. That meant I did a poor job of educating her and relating the pain science to her situation. After this happened several times where I was able to fill in the gaps, I’ve noticed that she’s reporting every little thing she feels less the greater her understanding of central sensitization becomes. We were also able to begin talking about how not every sensation = pain, tissue damage, or problem, and that there is a difference between the feeling of a stretch and tissue damage.
I was helped in this particular situation because her hypervigilance was paired with widespread symptoms that can’t make any sense. Therefore, I could politely challenge her to explain it and then reframe it with the missing gaps from pain science education. I think it would be much harder if it was a localized spot like the low back. I’m not sure how I would go about that situation.
I still sometimes forget the gap between what words mean to us and what they mean to a patient. For instance, when I hear RTC tear, I kind of shrug it off because I know it doesn’t necessarily matter. A pt hears those words and thinks life is over.
I was working with a patient post car accident and found some hypomobilities in their lumbar. When I was working on a particular spot, I mentioned that it was stiffer than I was expecting. She held onto that thing for the rest of treatment, wondering why it was stiff, how to get it unstiff, whether she would ever be normal. I had to fight that thing the rest of the way.
1) What do you think about my search strategy? Tips/pointers that you’ve found helpful for other literature searches?
Finding stuff on thoracic spine is hard because of its lower prevalence than other things we see. I also find it difficult to find the sweet spot of search terms where you have a manageable amount of articles to scan titles while not having too few. I’m not sure if adding physical therapy/physiotherapy would have beneficial here.
2) Read through my summary and the article, then let’s talk about statistics:
– What do you think about their findings in the results section?I’m going to try my best to untease what I think they did here — correct me if I am wrong. They compared between groups (A vs. B) and then within groups (where A started and where A ended up). When comparing A vs. B, the conclusion was:
“This indicates that both treatment approaches were effective in the
amount of disability and sensory dimensions of pain experienced by the patient.”However, when they compared where A started to where A ended up:
“This indicates that only the SMT group was successful in significantly reducing disability and amount of pain.”
This is such an odd switcharoo to find a meaningful finding. Sure, the treatment group showed significant improvement from where they started, but it’s non significant when compared to the placebo.
– Did they draw appropriate conclusions based on the statistics?
I can’t say they did with what they are trying to ultimately say which is that though it wasn’t statistically significant compared to a placebo that there were statistically significant gains made in biomechanical measures and that’s more important.
– What are your thoughts on statistically significant vs clinically significant?
I think there is something to be said for n = 1. The evidence for thoracic manipulation and shoulder impairments is poor, but if I do it and can find meaningful clinical findings for improvement, it might still be valid to do it in that situation. The only thing that can be clinically significant is pt report of improvement in things that are meaningful to them. In this study, it seemed like they were saying Thoracic SB is clinically meaningful….which is a hard sell for me.
3) Any other general opinions on the article?
I’m not sure what to think about it.