[sewhitta]

If he hasn’t already defined to you what he considers a “sprint” interval or repeat, I would definitely ask. This could mean something different to various types of athletes, or to novice or un-experienced athletes. To me, sprint repeats would be 100-110 yards all out sprints, followed by maybe a two minute rest break, repeating maybe 10 times. Very appropriate for a football player that maximally exerts themselves for 7 secs per play, followed by a rest break in the huddle. Not so appropriate for a long distance runner.

Go back to the three energy systems being used with activity: the Phoshagen system, Glycolysis (anaerobic) system and Aerobic system. Now, hill repeats for say 1-3 minutes at a time is appropriate to raise your anaerobic threshold to help you get over a steep hill. However, a 100 yard sprint for 15-20 secs doesn’t require much, if any, oxygen (Phosphagen system). Two different workouts, stressing two different systems for two very different activities.

Now, your guy may consider his sprint workout to be a high intensity interval track workout, performing repeats of 400 or 800 meters, at say a pace 30% faster than race pace, to improve strength and raise his anaerobic threshold. Or like he said, hill repeats for 1-3 minutes followed by an active rest back to aerobic. Very appropriate for a distance runner. I would definitely have him lay out and specify what he’s doing for his sprint workouts.

[sewhitta]

Reading this case really makes me want to know more about this guys running history, level of experience, past race experience and current training program. Marathon runners and sprinters are two very different athletes. I would want him to describe or define the “sprint” that he states he did at the end of his run and reason for why he was doing a sprint, given he’s training for a marathon. Was this sprint a one-time thing? How often does he “sprint” and how long has he been training in this manner? It seems like there’s a possibility in a training error on his part. I feel like if your goal is to run a marathon, the risk vs. reward is too great to add “all out” sprints in your training regimen. In my opinion, this just substantially increases your risk of injury with minimal benefit when training for a marathon. I think this should be investigated more and addressed during treatment to prevent future injuries.

I agree with Nick: the injury is sub-acute and the tissue seems highly irritable and exercise prescription should be dictated by pain. There could be chance he could make it to the starting line of his marathon, if his training as been consistent up to this point, and if he avoids overloading his hamstring by sprinting.

[sewhitta]

A bit late on the response I know.
I agree with you guys on the limitations to this study and the lack of task-specificity in the tests that were used. The weight of our functional assessment is determined by the relationship it has on the specific task the individual is performing. This analysis is based on our logic and what we know about the laws of physics, biomechanics and exercise physiology. It appears these tests are missing a few key components with its testing. I’ll have to look more specifically into the FMS to say for sure, but from what I’m seeing so far it looks like they’re testing one’s ability, mobility and strength to perform a movement for a single repetition (correct me if I’m wrong on that). This lacks assessing a key component of endurance in this population. I’m pretty sure these guys need to be working their butts off for hours on end. So why not challenge their ability to perform the task for a longer duration. When I think of assessing Functional Movement, I’m thinking of Task Specific, just as you guys said. For instance, take Blaise’s functional testing for runners that also challenges their endurance specific to running.

I think this just goes to show that we can do a better job at testing and treating function than the FMS. Thank goodness the results weren’t valid. Otherwise a robot could do our job for us.

[sewhitta]

At this point he’s doing well. He’s working, able to run and doing a little swimming (breast stroke) without issue. He has about 150 degree’s of shoulder flexion AROM, 70 AROM ER and IR still quite limited at about 45 degree’s. No c/o pain, just stiffness and weakness. He’s able to lift objects such as grocery bags with one arm, and perform his ADL’s without limitations.

[sewhitta]

Excellent comments guys, good discussion. Thanks for your input. I wanted to get your input as well in terms of how long it will take to reach a particular outcome or activity level. Obviously there are a lot of factors that play into this. I feel like sometimes, at least for me, I’m hesitant to provide a timeframe or unsure and that leads me to provide very vague answers. Maybe it’s just me, but this was the reason I wanted to do more research on this topic. What would you have said to this patient to answer the question, “how long will this take?” Would you treat for a month, two, six? Would you expect a plateau or a lull in progress at any point? Would you press on? Request more visits? Does your answer or the education you provide change after reading the articles.

This guy is awesome to work with, great attitude and always has something positive to say each day he comes in and never complains about his lack of function. He’s totally on board with rehab and really wants to avoid surgery. I initially advised him to improve his mobility and strength as much as possible before considering surgery. I’ve been treating him since March and he’s at the end of his 12 visits. He’s made excellent improvements, but his mobility and strength are still limited a moderate degree. My initial expectation was that he would have more mobility by this time. I wasn’t sure if he’s reached a plateau, if we needed to be more vigorous or if this was the natural course of the condition.

A lot of our patient’s may not be this easy to deal with and may be panicking at this point, especially if they’re worried about workman’s comp paying for their surgery if they need it.

[sewhitta]

Hey Alex,
Nice job completing your final Journal Club presentation. It definitely sounds like a tough patient case. I just wanted to follow-up with a point that stuck out to me during your presentation. From my understanding it sounds you agree there is a central component to this patient’s presentation and you are pleased with the fact that she is getting better, regardless of whether or not her improvement is a result of your manual techniques, exercise or the education you are providing. I agree, it’s great that she is improving. The point I would like to make is that I think it’s very important that the patient understand why she is improving, especially with a case involving a central sensitization component. In cases that have an apparent central component, even if there are still mechanical signs and symptoms that make sense, I want to focus all my energy on educating them on their pathology, set their mind at ease and see if that has an impact. If my education has a significant influence at relaxing the patient and their symptoms and movement significantly improve, it’s huge that they realize what helped them improve so they can manage the condition themselves. There are times that my strategies for a patient who have even a hint of a central sensitization component are to spend most of my time educating and begin low level, healthy movement and to be hands-off initially. I want to empower them to manage their condition independently and I want to avoid giving them the impression that they need me to perform treatment technique on them. Obviously this is a case-by-case basis. I realize that some hands-on techniques are completely warranted at times for a patient such as this and it’s difficult for me to say whether or not your patient would or not. Regardless, I want the patient and myself to know if she improves from my education, from my exercise or from my manual treatment, and to do that I feel like I need to perform minimal treatment initially to make that determination if I am initially unsure. To start, I need to make a determination of what component is the most heavily weighed and start there.
Thanks for presenting! It’s great to reflect on patients like this

[sewhitta]

Alex, thanks for posting
I think perceived improvement and objective improvement go hand-in-hand and the weight of one or the other is very much dependent on the patient. I think we could all reflect on a particular patient that may perceive they are doing really well but objectively they may not be and may require more specific patient education to avoid recurrent episodes, such as a post-op patient or someone with a reactive tendon or joint pathology for example. In cases of chronic conditions with individuals with fear avoidance and maladaptive movement behavior, patient interaction and education are critical and perceived improvement I feel is more important than their actual pain level. I feel if I can influence this type of patient to be more active, to move more and be more social in their community without an increase in pain, then that’s a win.

As for the demographics of the subjects in this study, I think it’s worth analyzing the potential influence of studies that utilize a convenience sample such as this. There will be a big difference in patient perspectives and biopsychosocial factors between someone who is seeking treatment because it’s significantly affecting their life and someone that participates in a study just because someone asked them or sent them an advertisement. I think these individuals may respond very different to the same treatment and our treatment selection should be selected carefully and be based on multiple factors when it comes to chronic LBP (fear, beliefs, perception of PT, past treatment, etc.) and not just on the fact that they have chronic pain with low to moderate disability, etc..

I can’t believe I posted something before Nick

[sewhitta]

I definitely have not had much success in attempting to change a patient’s belief on what they have learned from prior clinicians. I would say I’ve tried more along the lines of what Laura mentioned and attempt to uncover or provide an explanation to why the “out of alignment” is occurring and address the cause. I try to keep things as simple and as functional as possible and bring to light their impairments to provide an explanation. Just as Laura said, for example, maybe there’s a stiff joint, a tight muscle or a functional weakness that could be causing the issue. In an attempt to decrease fear, I’ll typically use the approach that I’ve gathered from O’Sullivan and educate them on the resilience and robustness of their spine and normal imaging findings. Sometimes all it takes is to just educate people that it’s OK for them to move. I love O’Sullivans flexed fist/wrist analogy to relate to the spine. I use this all the time now and you can just see the patient relax and a light bulb go off in their head after teaching them. The days of breaking out the spine model are over. I can’t believe how much I use to do that.

To follow up with Aarons comments, it’s definitely a red flag when individuals are seeking passive treatments. Again, I’m trying to educate them on us trying to get to the root of the problem. This is where I go back to the functional exam and relating those findings to their limitations and goals. If they think they have a short leg or a crooked spine or an out of aligned pelvis, I simply educate them that everyone is asymmetrical to some degree, especially at the pelvis.

On the subject of manual therapy, there is no question that our demeanor and placing our hands on a patient has an immediate effect whether we know what we’re doing or not. Our tone of voice, calmness, speed, vigor and even the temperature of our hands (mine are always cold, it doesn’t help) is felt by the individual and they either immediately feel comfortable or they can become even more fearful. I agree with a lot of what Adam said. If you don’t have an understanding of the biopsychosocial aspect to injury and pain and how to deal with people in pain, it doesn’t matter what technique you know. For me, the skill in manual therapy is when you know the anatomy of the body, have an understanding of what normal tissue and joints feel like and you’re able to determine if the abnormalities you are perceiving are relevant to the patient’s presentation. But, if you don’t have an understanding of the biopsychosocial aspect to injury and pain and your interaction with the patient elicits fear, it’s not going to matter what you know.

[sewhitta]

Thanks for posting Laura
I agree with Nick. I would need more supporting evidence to refer this patient out after your initial eval. The Hoffman’s test, from what I have been reading, is not reliable as a stand-alone test for a cord compression, and having bilateral symptoms is not as concerning as unilateral symptoms (correct me if I’m wrong). It also appears her symptoms are very mechanical. Going back to your physical exam, you mentioned you would add prone instability testing. Prior to this, I would palpate as specific as I could throughout the lumbar spine to develop an appreciation for muscle tone and any deformities in the spine (possible step deformity with spondylolisthesis). I would add PPIVMS, PAVIMS and PA’s, again to get as specific as possible to the area in question if you are thinking the spondylolisthesis could be the source of her symptoms. If it’s not provocative, great! That’s a great opportunity to educate her further on the lack of correlation between the exam and the MRI findings, which could potentially set her mind at ease if she is having any sort of fear of this “deformity” in her spine.
As far as her prognosis, this is always tough for me to address with these patient’s. At this point in my clinical reasoning I try to explain back injuries by comparing it to other tissue injuries, such as an ankle sprain. Depending on the tissue involved and the severity of the initial injury, the tissue could take months to remodel and longer to restore strength and motor control. I think it’s important to convey that expectation if it’s necessary. According to the LBP Practice Guideline, there is a high recurrence of episodes of LBP after an acute LBP episode, and 60% of those episodes occur 2 months after the initial episode. When I sprained my ankle, I tried to play basketball 3 months later and sprained it again (3 times in one year, most likely because I did nothing to rehab it). I think patients often are discouraged when they feel they’re not getting better because their expectation is not realistic and they lack knowledge of the physiology of tissue healing. In addition to that, it can be tough for us as therapist to tell someone who is very active that they may have to stop doing something they really love and we really want them to get back to activity as quickly as possible. However, I feel it’s necessary to plant the seed at times and let them know, this may take a while. For the appropriate patient, therapy once per month with quality patient education sessions may be the best route and all they need. I mean, how many times do people come back each week, 2 or 3 times each week and tell us “nothing has changed”? Well, it may need more time to change. I have also found that less frequent visits seems to hold the patient more accountable to take charge of their care and not rely on coming to therapy visits to be “fixed” by their therapist.
I think it’s also awesome as well that she received consistent information from multiple sources regarding her condition. Can you imagine how much that would affect outcomes if that were always the case?

[sewhitta]

Kristen, my guess is the foam roll is providing tactile feedback and you’re cuing the patient to squeeze the foam roll with their scapula with elevation, which could be an external cue. It may also give you room to put your hands on the patient’s scapula to assist the motion in a more gravity assisted position in an inclined position. Am I warm?

It has definitely been a challenge to train patients in this motion and scap activation. Since I’ve read this article I’ve tried the exercise with elevation plus band ER and I’ve found it to be helpful. It’s definitely challenging, but very effective for the right patient. I’ve also tried, with less success, having the patient try and hold a short foam roll between their elbows with the elevation and band ER. It didn’t workout so well, but I like the idea. I may try it again with my higher level patient’s.

[sewhitta]

This is such an invaluable document. Thank you for sharing. The EMG data that is given in the protocol phases is really helpful and appreciated. It gives me a visual reference to go along with the exercise being performed. I have in the past definitely moved these patients along faster than they should be. The algorithm provided in Appendix 2 is a nice reference to help organize my little brain and help aid in problem solving with these patients. While it is realized that each patient requires their own individual approach, the Appendix is particularly helpful when prescribing frequency of a HEP. I feel there is always a fine line between prescribing a home program that is beneficial to improving function, but does not reach a threshold of causing irritation or damage and allow healing. Having a better understanding of the tissues involved is obviously critical.

[sewhitta]

Yeah Nick, I think Monday we should play around with some of these strategies illustrated in this article. I’m not quite sure about the external cue they give for the knee, “reach for the cone with your knee”. I’m guessing they mean the same as saying “point your knee at the cone”. Jay’s lecture at the conference really brought to light the importance of making therapy more enjoyable, more challenging and more fun. I feel like I keep doing the same things. I love the idea of the games and the technology for visual cues and feedback. My problem is, I don’t have the technology, or even a smart phone for that matter. So, I’m concocting a few inexpensive visual feedback apparatuses that involve a bicycle tail light (with “laser beams!”) with a Velcro strap and a clear tube with a ball inside. This should be fun. I’ll let you know how it goes.

[sewhitta]

Nick –
As I mentioned before, I love this topic on multiple levels and I think valuable discussion could come from this to help us all, or just me, problem solve to find where and how to incorporate manipulation treatment into practice to achieve the most benefit. The faculty has brought up the topic of when and if consent should be implemented prior to treatment as well and I think this could fall into that topic with a different perspective.

For instance, I would say that I implement manipulation therapy in my practice a fair amount when I feel it’s appropriate. I feel fairly confident in my skills; however, I feel very apprehensive to “pull the trigger” on performing a “thrust” at times, particularly to the cervical spine. My biggest fear is that I surprise the patient to a degree that causes fear in them and I lose their trust. On one hand, I feel like asking for consent could cause fear and apprehension and may come across as a lack of confidence on my part. On the other hand, I want them to have an expectation of what I am about to do. So far I’ve used phrases such as, “this joint feels really stiff, it feels like it needs to pop, I think that would really help you”, etc, and then I just wait for a reaction or response. I’m exploring different approaches to this issue. Maybe I’m just over-thinking it. I realize some clinicians may just go right into performing the technique without warning. But I just feel a need to have an understanding of their expectations of therapy.

I noticed in this article they just told the patient’s they were going to “push” on their back. It doesn’t look like they informed them of the high velocity thrust. I kinda like the idea of showing a video as they did in this study. Maybe a video in addition to providing patients with the “JOSPT patient perspectives”, that were included in Aaron’s (or AJ’s, can’t remember which) presentation, is the way to go. This may be stating the obvious, but I think if we are planning to manipulate, we should definitely be asking the patient if they have seen a chiropractor and what their experience was like if they have.

Does anyone else share similar thoughts? What approach has been successful or unsuccessful for you (residents and faculty)?

Regardless of the technique being performed, providing more positive feedback and exuding a positive outlook to the patient regarding their therapy outcome is extremely valuable more than anything else we do. Maybe in my practice this has been more pronounced as my confidence grows, but this is one of the biggest changes that I have learned from Eric and Mike and have made a priority in my practice. If we could just influence other healthcare professionals to do the same thing, we would really be in business and on track to changing healthcare and dollars spent on healthcare.

[sewhitta]

Oksana –
Nice topic and article selection. I have used “soft landing” or “run softly” cues with patients’ often, to decrease GRF as well as patellofemoral joint compression forces. I’m surprised at the findings regarding decreased hip angle and GRF. I ran across an article a few months ago that looked at knee, hip and trunk angles and correlations with GRF and patellofemoral compressive forces. They found increased hip and trunk flexion resulted in significant decreases in GRF and joint compressive forces. I often cue athletes, when jumping or with SL squats, to drive their hips back and bend forward at their waist. This has been helpful for me and often results in decreased patellofemoral pain.
To comment on the patients’ symptoms with his squat and single limb squat. You mentioned you noted some abnormal movements and it was painful. I would try to immediately follow that up with trying to correct his movement with verbal and tactile cueing and see if that changes his pain level. If it does, I’d use that as treatment to help him move better and assist with decreasing GRF and tissue irritation and spend a lot of time educating him on the rationale.

[sewhitta]

Nick – I completely agree, we don’t have the public respect. That’s why I feel it’s absolutely necessary to have more of a voice to the public. I feel I’m often going against the grain of what MD’s are telling patient’s all the time. That’s what’s so frustrating. Treatment would be so much easier if the MD, instead of me, told the patient these MRI findings are normal. However, it’s not against the grain of all MD’s. This article was published by MD’s. It’s only against the grain of MD’s that aren’t aware of the current literature, or who choose not to utilize it.

So, question for everyone: how do we establish this voice and what else could we do to facilitate a change?

[Author]

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