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In thinking about this patient, I may question whether I think the lateral wedge would make a big difference. The 2017 systematic review in BMJ highlights that the addition of arch support to a lateral wedge normalizes ankle and foot motion, but limits reductions in the knee adduction moment. I think katie has another interesting point, in his choice of Hokas, following that he seems to have some neuromuscular control and strength deficits with SL squat/step down and a heavy landing with hopping…Jay talked about how too much cushioning may promote landing with increased limb stiffness and can lead to instability due to less proprioceptive feedback for stability. There just seems to be a lot going on with him trying to use this path to control symptoms (orthotics to manage shin splints, Hokas to manage previous knee pain). I definitely get the reasoning behind its use and to keep him running, but would want to encourage those proprioceptive/motor control exercises (i.e. first ray stability with exercises to promote moving out of lateral column loading) and discuss his training schedule to hopefully give him a feeling of more internal control over his symptoms along with external support. In my experience, runners are always a difficult patient population to manage expectations and find the right workload ratio – keep us posted!
The quote in this article: “Rarely does the literature outline a definitive set of signs or symptoms that are unique to serious pathology of the low back—for either the screening OR the diagnostic phase” resonated with me for this patient population. I think the red flags are important to be aware of, and as Jen said, have a baseline of symptoms and information to monitor over time. We get to chance to see our patients more frequently than most other healthcare providers, so we have the opportunity to closely monitor symptoms over the course of time and refer as indicated. In reading one of the references listed in this review for primary care providers – it can be difficult to manage patient fears…”Primary care education also aims to help the clinician learn how to handle uncertainty when further pursuit of a disease diagnosis is unlikely to influence the choice of treatment or alter the patient’s outcome” and this uncertainty can often lead to unnecessary imaging or “overdiagnosis”. To follow what Tyler said, I think the “gray area” makes this aspect of practice challenging – there is not a simple answer and potentially why people like Chad Cook continue to question and research this topic.
I definitely can better monitor RPE to progress and prescribe exercise, both with my athletes but also my older patients. The acute:chronic workload ratio and spreadsheet was a big takeaway for me as well. Especially coming into the fall, when we get a lot of chronically under-loaded athletes over the summer starting school sports. I agree with Jen with using all of the tools we learned to get better buy in from day one. Making exercise prescription even more personalized and discussing it with the patient – i.e. your goals are “x,y,z” and then deciding together what they can realistically manage to do at home and what will be the focus in session (1 day of endurance, 1 day strength, etc). Further monitoring RPE not only makes sure we are not underloading but helps with patient buy in as well.
Hey Tyler,
I think teaching isometrics if they are pain-relieving could still be beneficial. As you progress her program, they could be used on the off days to manage her symptoms. I would also be curious to see how she is stretching her hamstrings and what she feels about yoga is beneficial (again thinking along the lines of Justin – could it be core/pelvis positioning having an impact). Potentially an indication to add exercises focused on lumbopelvic stability, etc.
“She had physical therapy in 2016 which helped decrease symptoms. She has tried chiropractic care, steroid injections, acupuncture, and dry needling without relief.” She seems to have tried a lot of passive interventions without success – but PT has helped in the past…do you know anything about her previous program?
I was also curious about the nature of her LBP symptoms? Does she feel LBP when running or with similar aggs to her posterior thigh/glutes?
Great read, Katie. Thanks for sharing!
I think this type of language and patient education can make or break an evaluation. Many patients come with some type of misconception or are already catastrophizing – whether it was due to something their MD, the internet, or friends have told them. Finding the right balance of information is difficult, being able to parallel with the patient is a skill that I continue to work on. I have used tools like the JOSPT perspectives for patients to help reinforce education and I always try to leave room for questions at the end of each session.hey Justin, this is what i could find…”Gender has also been shown to be a significant intrinsic contributor to development of degeneration instead of remodeling, with tendons from females exhibiting decreased collagen synthesis rate in response to acute exercise and dampened hypertrophy in response to habitual exercise. However, while correlations between incidence of injury or retear and these contributing factors have been identified, the mechanisms by which these factors alter the biological environment or govern the mechanosensitivity of the responding cells remains unknown.”
Katie!! my response was just deleted because I apparently was not signed in to post. However, I was thinking along the same lines as you in terms of first addressing the cervical stiffness and a trial of the Elvey technique to address the system irritability. You also addressed my 2nd main thought in that his worst pain is in the AM (gets better throughout the day) so addressing sleeping position may be beneficial. He sounds like he goes from sitting all day to some potentially heavy house/yardwork in caring for his garden/cattle and wonder if poor repetitive body mechanics may be playing a role (stiffness/poor posture/repetitive pushing and pulling) so would be curious to see the continued impact of posture re education/strengthening on his symptoms. Thanks for the post/update!
I think you mentioning that “This episode is worse than before, does not feel similar” would lead me to be sure that I though manipulation is appropriate this time around, relying on my clusters of symptoms/CPRs to help my potential bias (and his) towards picking a treatment based on someone else’s treatment. Sounds like he has already bought into the PT process, so I don’t think you are likely to loose too much by not manipulating the first day. I think education is key, giving him self treatments that are successful (whether its SNAGSs, stretches, etc) so he feels like he has control of his symptoms and may be less fearful when he finishes his medication.
I thought it was interesting that they pointed out the review by Couppe et al that it may matter less the type of contraction you are using (eccentric vs concentric) and more on the # of reps at the appropriate load, speed, and duration for the specific patient. Thinking about the AT force and stress during running is much higher than typical dosage used in the clinic and needs to be a factor when developing a return to running program. A previous 2015 JOPST article I have used in the past, “A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation” highlighted the importance of education in return to sport to modulate expectations and prevent exacerbation of symptoms. This current article will also be useful in helping to explain the loading progression and how certain functional exercises (lunges, squats, etc) may place different loads on their tendon.
Hey Tyler!
1. I would be thinking TOS for differential dx and also would want to rule out peripheral entrapment.
2. For objective measures, I would focus on the cluster of findings that would either reinforce or rule out my primary diagnosis (i.e cervical ROM, spurlings, distraction, etc) — it sounds like she is wary of treatment so spending the time on education and getting objective measures along the way may help with patient buy-in.
3. I like the ideas you had in using techniques that can be performed in seated, including MWM, postural/stabilization exercises, why she is more acute. In terms of manual techniques, I would just make sure I had a re test I could use to make sure symptoms are not worsening with my treatment.Reading and interpreting the literature can be difficult for me. Deciding the quality of the study, if it applies to my patient (per demographics, condition, co-morbidity), how to apply in my setting (incl time and equipment limitations). My own biases are something that becomes even more apparent every time I work with a new PT student. I find myself going back and questioning myself with common conditions I see, i.e. shoulder impingement and low back pain. I think this is especially true with treatments that I have found effective in the past for these conditions. Confirmation bias is hard to overcome as we are hoping treatments our treatments are effective, and I try to rephrase my questions during eval and/or treatment to avoid leading the patient and allow for a more open ended answer that may be more truthful.
I have used Katie’s first article before and I always think of this quote with patients with central sensitization: “…education of the central
sensitization model relies on deep learning, aimed at reconceptualising
pain, based on the assumption that appropriate cognitive
and behavioural responses will follow when pain is appraised as
less dangerous (Moseley, 2003a)”. Fear seems to be a big limiting factor for him, both with exercises and in his life (fear of losing his job). Education could go a long way for this patient – which I know you have done — sometimes videos (moseley ted talk, etc) or giving him articles to read at home can reinforce the concepts you discuss and he can think through it in a lower stress environment.Since I was only able to make the Thursday portion due to another course Friday, It is helpful to hear some of the pearls you guys though were helpful from Friday and plan to look over the handouts! I thought the presentations were interesting regarding how difficult it can be for surgeons when deciding on appropriate patients for surgery (esp with the hip and shoulder labrum) and really saw this as another way PTs can work with physicians and the patients to make the best decision for each patient. Another big takeaway from Thursday was the importance of connecting with your patient, as it’s not always what you know, but how you relate that to the patient for both buy-in and understanding. I think this is something that takes a lot of practice and is so variable person to person. As VOMPTI has taught us, the subjective portion of the exam is vital to understanding your patient and setting meaningful goals.
Sounds like there are still some motor control issues. I think you said that you have watched her run before on even surfaces, but I would be interested to see if she had any issues (compliance, bounce, overstriding) that we can see and potentially show her on video. As for RTS, the quad and hamstring weakness would be a big part of the patient education I would give (maybe even show her how she looks with the hop tests) to emphasize the importance of her HEP. She also is still having pain when stepping over a backpack slowly so I would also want to talk with her about the potential difficulty with navigating uneven terrain (and risk of tripping) during trail runs once fatigued.