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I tend to take three or four things from multiple systems (function, active, passive, joint mobilization, neuro, MMT, special test, etc). That way I can capture the array of things our techniques can change. So using Helen’s patient as an example, I might have that person run in the clinic, FABER, AROM Hip Flexion, TTP to psoas and then do my treatment and check those four things for changes. That way I can see what gets better or worse and go on to the next thing so I know how big each slice of the “pie” is with each patient (for instance, if it’s more about soft-tissue restriction, then you will see more improvement with your objective *s with those interventions vs. joint mobilizations vs. motor control).
I practice this way all the time. Stealing Aaron’s pie analogy, every patient has multiple impairments, we just don’t know how big each slice of the pie is. I would imagine the only way to figure that out is doing an assess-treat-reassess as you begin to funnel through the Objective * list using clinical findings to inform your treatment.
With your particular treatment Helen, you used running as an objective * and did STM, Joint mobilization, and motor control to find which intervention fit your patient. I approach problems like this all the time until we can do more pattern recognition via building up a rolodex through more patient contact.
The only thing (which you may have done but didn’t list due to brevity) was finding impairments that matched those interventions. So if FABER, FADIR were positive, looking for side to side differences in joint mobility to have more evidence to do a joint mobilization. Same for soft tissue (difference in side to side upon palpation or + MLT). I find having that interim objective * helps reason through impairment list and avoids the shotgun approach… which I admittedly have done at times.
This was an exquisite article that breaks down the problems with being absolutely dogmatic to one way of thinking (SIJ is the source of all back pain) when there isn’t much validity, reliability, or pathophysiological backing to it.
However, it made me think: what other dogmatic things am I carrying around with me? There are tons of things I do in clinic that are along the same lines. Joint mobility reliability and validity can also be questioned, but I still do it and tell the patient a “story” based on my own biases. When I talk about scap dyskinesia or some other biomechanical principle, how do I know I’m not doing the same thing as the SIJ advocates?
I would like to think I can lean on two different principles that make it okay to do so: Using the assess-treat-reassess model; avoiding Nocebo education. If a patient wants to lift their arm overhead for an ADL and I do a joint mobilization after seeing shoulder elevation and it improves upon reassessment, I feel like that’s enough clinical evidence to feel good about my biases. Then, if I educate the patient on how to do it themselves (avoid dependency) while avoiding scary language (out of place, dysfunctional, etc) and get them moving again (addressing fear avoidance) then I’ve done what I can to live with my own biases.
I think it’s only a matter of time before something we believe goes through the same thing that SIJ focused people are experiencing right now. As long was we do are due diligence to be patient specific, use clinical findings to drive treatment, and don’t instill negative beliefs, I feel better about navigating the ambiguous 14 lane highway of PT.
1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?
– Labral pathology
– Secondary Impingement
– RTC Tendinopathy2) Are there any objective tests you feel would provide a clearer picture of this case?
Due to his scap having observational/movement impairments, assessing the PAM of shoulder blade. Also, what’s the MMT of those force couples involving the shoulder blade (LT/MT)? I’d expect based on the “pattern” that his humeral head is sitting too far forward — what’s his GH IR and posterior glide of GH Jt look like?
3) Do the objective findings fit a clinical pattern? If so, of what?
Yes – Labral pathology with some concomitant irritation to RTC.
4) What impairment or limitation would you want to address first with this patient?
Pending the results of PAM and some other things, I would focus on posterior glides (THE glide) to get that thing sitting back where it needs to then following up with exercise.
1) Looking ONLY at the body chart, what is your primary hypothesis?
L3/L4 Lumbar Radiculopathy
2) Looking at the body chart AND subjective exam, now what is your primary hypothesis? Next 2-3 differentials?
Hip OA
Labral/Impingement
Lumbar Referral3) What are some other questions you could have asked to help rule in/rule out your hypotheses?
– Popping/Clicking/Catching.
– Clarity on 24 hour pattern.
– Problems with certain sleeping positions.4) Does the objective information/patient presentation make you think of a particular diagnosis?
Seems very OA — global ROM loss; Aggs/Eases; 24 hour pattern; pt demographic; (+) intraarticular testing.
5) What would be your first thought on treatment for this patient?
Obviously I first think of manual therapy to improve range of motion, but let’s get her more active (motion is lotion). She already reported that she felt better when she worked out so it should be an easy educational moment. Let’s see what activity she could do (recumbent bike?) and then go from there pending irritability and pain.
I could talk all day about external cueing.
I have never treated an ACL pt to date, so I would be in the same boat. I’m interested to see what other people’s ideas are. The one question I am willing to throw out a suggestion for is:
2) What are your go-to techniques to gain terminal knee extension and get the patient to utilize it during exercise and gait?
As far as manual therapy, I really like doing a posterior glide on the tibia (at about the tuberosity) while pulling upwards underneath their foot. While not matching the biomechanical rules (PA on tibia/AP on femur) to get knee extension, I have found it to be more tolerable for lots of populations and shows improvement post assess-treat-reassess. I remember someone also pointing out (probably Aaron) that since it isn’t stressing the anterior translation of the tibia, it may be something you could do earlier as it shouldn’t endanger the graft.
As far as return to gait, at my Brooks Rehab rotation in outpatient neuro there were a lot of nifty things we did to get people as within context as possible to retrain things.
We actually talked about this exercise before and how I need to show you in person. Where you need that TKE is middle midstance into beginning terminal stance. I get them in that position by putting their unaffected LE on a step to force weightbear them on the affected LE behind them. From this position, you can have the pt work on TKE resisted, calf raises while preventing that knee from bending, and more to have it as within context of the phase of gait where it needs to happen while providing them enough balance for them to focus on the motor control aspect.
Treadmill pushes, where the patient works on just pushing back on a treadmill that is off, is another way to facilitate what you want during the gait cycle. In that particular instance, you can be off to the side and facilitating what you want through hand placement.
If we ever remember, I’ll show you at the next VOMPTI course.
I think the biggest parallel I see is you have to commit/predict to something before you go into your objective exam. I had a patient who seemed cervical radiculopathy, but there were some question marks. I still committed to that as the primary, but when rotation, spurling’s, and extension were negative, I was able to think in the moment that this isn’t what I expected and therefore might not be what I think it is. If I hadn’t predicted what I would see, I think I would have collected all the data and then reflected at the end of what it could be instead of doing it more within the moment.
I think that the act of making a prediction makes you invested and gives you something meaningful to engage with. It forces you to be thoughtful during the entire process.
1) Is there any more information you would have gathered during the subjective? Are there any other outcome measures you would have administered?
I find with MVA an Impact of Events Scale gives you a lot of insight into the yellow flags surrounding cases like this. I would have also liked more detail about exactly what occured during the MVA (body positioning, what happened immediately after, etc).
2) Based on body diagram and subjective exam is there anything else on your differential list? Is there anything you would change on mine?
I think you have a strong differential list.
3) Considering irritability would you have changed your objective exam? What would you have done differently?
This is hard to talk to without having the patient in front of me to gauge their reaction/buy in, but I might have been hesitant to do quadrant testing on day one due to it being the most provocative test. You also withheld mobilization testing which was probably appropriate given that amount of irritability.
4) What is/are your primary hypothesis or hypotheses?
I’m not sure how to describe this or if we have enough information yet due to irritability being so high and not being able to test a few more things out (I don’t see we reproduced the HA, but we PA testing was withheld so who knows). Right now, I feel comfortable saying we have some upper cervical, mid cervical, shoulder, and myofascial impairments.
5) What would your PICO question be for this patient?
Is manual therapy or therex better for people who have been in a MVA.
Working hypothesis and differential diagnosis:
a.) What is your working hypothesis regarding this patient?
– Cervical Discogenic pain with torn shoulder labrum.b.) What are your next 2-3 differentials? (Ranking order)
– Upper Cervical Facet, Mid-Cervical Facet, Thoracic
– RTC Tendinopathy, Impingement, RTC TearSpecial testing:
a.) What are your thoughts regarding the special testing chosen for this patient?
– I think the cervical radiculopathy cluster was warranted.
– While the impingement type tests were a mixed bag (arc, ER, Scap assist), I think it helped clear out some of my differentials and gave me a big indicator of treatment options with scap assist being +.
-Given MOI description, I think it was a good choice to have done the apprehension test.b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?
– I know there are a thousand other labral tests, but finding that he does have (+) apprehension, I wonder if it would have been worthwhile to try and reproduce it with other ones? I’m not sure this would have really changed your treatment plan, just food for thought.
Clinical Pattern:
a.) Does this patient’s presentation fit a clinical pattern?
– I feel comfortable saying the scapular pain fits a discogenic referral and the provocative factors back that up. The shoulder is a mixed bag and I’m not sure I feel as confident saying he’s just one category: it looks a little labral, a little scap dyskinesia, a little muscular.b.) Briefly, what are your thoughts regarding his headache?
– Kind of a curveball with everything else going on, but you reproduced it which makes me feel it is more mechanical. I bet if you did some CPA/UPAs, you could find which of the upper cervical are involved.Evolution of Patient’s Symptoms:
a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.I think that’s how most of us live our lives: we have some aches and pains that aren’t too bad so we ignore them; they eventually get harder to ignore; then we have an event that puts us over the top and we go see someone.
b.) Are there any red flags?
– None that I can see.1) Conclusions:
I say overall yes. The only concern I have is I tend to look at the difference between groups and the difference within group to see if there is enough distance to make a firm conclusion. It seems that the huge deviations between the data sets meaning there is a lot of overlap between the two groups. This to me speaks to some of the problems of generalizing this information as there were many people within the study itself that the conclusions did not apply to.
2) Which components of this research study reflect realistic / contemporary clinical practice? Which components seem less relevant to what we do in the clinic? Be specific.
It is scary to me the definition of “routine physical therapy.” I would hope doing some sort of clinically reasoned application of mobilization with other treatments would be more beneficial than just a sheet of exercises done everyday. More realistic are the clinically reasoned mobilizations while the less relevant being the modalities and isometric holds.
3) Are there additional limitations of their study methods or results beyond those mentioned in the article itself, and if so please describe. (Research by design is not perfect, we should be willing and able to poke holes in studies even if the authors don’t do it themselves)
It’s always an external and internal validity battle. They eliminated all these people with comorbidities and findings, but most of the patients we work have additional findings. It’s rare to find someone with just mechanical neck pain with no neuro, disc, or previous treatment history. This is not a fault of the authors since they were leaning more internal validity, but it is a limitation inherent in the study design.
4) How much time did you honestly spend looking through this article? Do you feel that it would be realistic to spend the same amount of time on a similar article while in clinic with a challenging patient? What are some perceived barriers (beyond physical time) that make it harder to translate research findings into clinical practice?
30 minutes due to getting Eric’s reminder e-mail this morning and having work at 9. Even though I steamrolled through the article, I still wouldn’t have 30 minutes of time within clinic as I start to see 14-16 patients a day. I think my biggest concerns with applying research in general can be found in this email I sent to Aaron a few weeks ago:
“Reading research takes a long time and to dive this deeply and analytically takes an even longer amount of time. At the end of research, most of it isn’t applicable or has too many problems and then because of the nature of N =1, none of what we read may be beneficial to the actual patient in front of us. I sometimes wonder about bang for the buck. I want to stay up to date on research, but after all the effort to avoid getting hoodwinked or to really understand patient application, it could be a small return on investment.”
After all, nociception is AN input, just not the ONLY input. I like the idea of considering how much PSE they need.
Brian: I liked the idea of loading different aspects of their contextual factors to further their gains, too, but I’ve had trouble figuring out the best way to go about that. I’d be interested if anyone has given that a go. I had a patient that may have benefited from this (her shoulder pain increases with stress and always on Sunday) but trying to find the “trigger” escaped us both, so I felt like I needed more info before trying.
Steven: I always think of the black knight off of Monty Python when I think of the problem with a pure pain science approach — most likely if your arms are chopped off, you won’t be doing so well (unless it is a hammer through the neck). So I usually consider if the person needs a little or a lot of PSE via their thoughts and beliefs about their acute or post-op surgery.
I guess manual therapy really doesn’t matter.
Just kidding!
I agree with Brandon that I was expecting more of a how to, but then I realized his approach is for you to really understand the problem and figure out how you want to deliver it. More responsibility on our end, but probably leads to better outcomes.
One of the things I realized I was doing was using the bio-psycho-social model inappropriately. The way I discussed this with patients previously was to tell them they had an initial injury that was being upregulated or downregulated by all the other contemporaneous factors. My spiel was usually “Take two people with the same injury. One isn’t sleeping well, smoking, not working out, depressed, stressed, not enjoying life and the other one is doing all of those things. Who gets better faster?” It’s intuitive that the second person is in a better position, and it was always a good “in” to start talking about other factors that are affecting care.
The main reason I did this is because there is no way for the patient to accuse you of it being all in their head. It’s a safe way to navigate dangerous waters. After seeing these talks go horrible wrong, I have a bit of fear avoidance when talking about people’s fear avoidance.
However I learned that this approach is probably not effective given some of the studies he showed and what take home message participants end up leaving with. It doesn’t get at the core of the problem because I’m doing the switcharoo with tissue damage vs. protection that’s easy to fall in.
While I’m not sure how to use this on a person who is in the thick of Chronic pain after 25 years, I do realize that its easiest application is on patients before it starts. We can actively steer people away from chronic pain venues by tackling MRI reports, irrational thoughts, and contextual factors early instead of letting it spiral out of control. We can be more careful in our choice of words and make sure people are instilled with resiliency and safety instead of fear and fragility.
I really like how these two tools assist in organizing your thoughts, but more importantly, help you look back and see where you could have done better. By committing to paper your thoughts in the moment, you have a history of what you were thinking for better recall and reflection later. That way after the whirlwind of the patient interaction is over, you can have more brain power to see where things went well or didn’t. I find myself lamenting questions unasked or measures untestested. This way of thinking should be very beneficial for those instances.
To Helen’s point, the subjective is such an important piece of all this at it seems like these two resources speak to it: a good subjective is what sets you up for success. I just did an eval yesterday for someone with multiple complaints, and I did a poor job of delineating the subjective to ask questions about each complaint and skimped out on details about the foot. I couldn’t find a darn thing wrong with it later on or recreate her symptoms.
And then it came to me after thinking about the rest of her history: “have you ever had shin splints before?” “Oh yea, that’s exactly what it is.”
That would have saved some time.