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*Subjective history: Making sure to be very specific with when they feel pain, at what point in their running gait cycle as well as how long into their run – in order to be more specific with hypothesis on what bone is affected. Question whether their pain resolves as running continues or does it remain throughout and cease afterwards, etc. *This article highlighted the importance of a thorough subjective history as special testing and imaging have low sensitivity. Asking the right questions in terms of past history (and even maternal history) of BSIs and asking specific questions about diet and training changes can help guide decision-making.
*Suspicion on differential: Have they had past BSIs, have they had a recent increase in training intensity or change in running surface, footwear, diet, etc. Suspicion of female athlete triad after subjective may have but BSI higher on my list.
*objective after h/o stress fracture: Do they have tenderness to palpation, warmth to touch. Gait and single leg task analysis would be important. Furthermore, addressing possible predisposing factors (muscle strength and control, core, knee, ankle stability) in modified positions depending on stage and irritability.
*treatment: I though this article was great for it’s emphasis on education and being very specific on return to running program. I have found that runners are quick to ignore pain and run through injury so having a specific plan is important (when to stop, when to progress, and what they can do in the mean time to maintain cardiovascular fitness)-“Do no harm”, imaging is often overused, do not order/recommend if they are not of diagnostic importance. However, can be beneficial to link the radiological signs with the patient history and examination findings when appropriate.
-Imaging can be an important component of your comprehensive evaluation. PTs can play an important role with our examination to ensure common mistakes are not made, such as: areas of referred pain imaged, missing associated injuries, and finding irrelevant pathology.
-Use of the ABCs system for radiographic evaluation.
-Understanding of specificity and sensitivity in imaging. If you pre test probability is high – more sensitive testing may be needed.I think that your patient fits the criteria in a number of ways in terms of chronicity and symptom referral. To the point a few others have made, I think manipulating adjacent segments can still achieve the analgesic/neurophysiological effects we are looking for.
I think this article was helpful in that it highlighted how useful manipulation can be for those who are in a lot of pain. At the 1-week follow up, patients in the manipulation group had a significant decrease in pain comparatively, which could be beneficial for patient buy-in and allow for other treatments earlier on. Tyler mentioned addressing the underlying issue with exercise following the manipulation. I agree that solely relying on passive treatments does not empower the patient and give them tools for self management in the future. I liked this study, but I would have also liked to see if exercise + manipulation would have yielded improved long term results. Furthermore, the article did not discuss the conversations and education that took place between patient and therapist that could also had an affect on patient expectations. I would also be curious about the conversations you guys have with your patients when discussing the role of both manual therapy and exercise in their treatment?
I have definitely been in similar situations. I recently evaluated a patient with shoulder pain and one of her first comments to me was that she has always been reluctant to go to the doctor. She had put up with her pain for 3 years before going to the MD and was very fearful of exercise and movement. I think this idea of behavior change and motivational interviewing is something that will be important to apply in her case, as she is lacking intrinsic motivation and is fearful of exacerbating her condition. I have thought about this in some of my self reflections as well. It can be difficult to find the right wording in the moment and I have been guilty of giving unsolicited advice, when the patient may have not yet been ready or willing to hear it yet. I like the strategies this article suggests for giving advice, providing information “in a neutral way that leaves the personal interpretation to the patient”.
I agree with Justin that PTs need to be better and forming relationships with MDs in the area to advocate for therapy/conservative care first. In my previous clinic, we had a more elderly patient population, and many with chronic LBP. Often times they would come into the clinic having already met with the spinal surgeon (and often given opioids). I think a big step towards impacting the findings of this study can be made in making sure that across the board we are all performing comprehensive assessments, educating, and listening to our patients. It takes trust in the health care provider and buy-in to the program for us to make a difference. We are lucky enough to be able to spend more time with our patients then the average primary care doc, and should take advantage of that. I thought the article Katie posted was very interesting, as well as a great educational tool. The statistics are hard to believe, especially for those who used opioids prior to surgery.
I really enjoyed reading this study. I found that many aspects of what makes an “expert clinician” were in alignment with why I chose to apply for residency after working for a few years. I have found that staying up to date on the research can be difficult (in terms of article acquisition outside of JOSPT and finding the most high-impact studies) and look forward to improving my skills in the next year. Furthermore, I have already realized in the past week, that having colleagues willing to discuss cases and broaden my perspectives on patients can facilitate my own personal growth. The last point that really stuck with me was in regards to how experts applied knowledge learned in continuing education. Having strategies for practicing new skills and incorporating it into daily treatments is key. As they pointed out, it is not the acquisition of advanced certification that matters, but making sure you are applying it in a thoughtful way that keeps the patient involved.
My favorite aspect of this article was the constant reinforcement of the importance of patient centered care and education. I think that the most exciting, and challenging, part of being a physical therapist is empowering patients and giving them back control of their pain. I have found that there is always room for improvement in this area, and what works for one patient may not for another.I agree that having this tool is a great way to hold yourself accountable and make sure you are thinking critically about each case. I like the discussion in the article about what makes an “expert” clinician, citing their “ability and willingness to consider, document, and test alternative hypothesis”. I have found in practice (through my own mistakes) that the source of one part of the pain is not always linked to the other. It’s easy to get caught in my own biases and not dig deeper. I believe that this tool will help to facilitate a more thoughtful examination and make treatments more efficient.
I also agree with Justin, I hope this tool will improve my decision making and my ability to articulate and fully understand those decisions. I think the PICO section and article review will be helpful to lay out and reinforce my thought process as well. I think the incorporation of article review with each patient will help me learn how to better analyze and relate current research and help make more informed decisions along with my own clinical reasoning.