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Yeah it’s frustrating for sure. I feel the big issue is that a large portion of clinicians have no incentive, or perhaps desire, to search for this research or to change their common practice. Additionally, there is no one that is questioning their practice and holding them accountable for their decisions. It’s very easy for a clinician to fall into a habit of doing the same thing, over and over again. The fact is, these physicians have little to offer these patient’s, and they want to be responsible for making the patient better. If the clinician isn’t trying to find a better and more reasonable treatment approach, they’re not going to find it. They will continue to do things the same way. This is not just physicians, its physical therapists as well. Clearly the evidence needs to be thrown in their face to put it into practice. So the question is, how can we change the practice? The way I see it, there are two options: 1) the media, and 2) direct access for physical therapy. The public needs to make the decisions. If we can get the message out to the public, and they demand alternative treatments to medications and surgeries, then clinicians will likely change their decision making process. If the public knows that disc degeneration and bulges are normal, then hopefully, they will question their doctors and seek other treatments. Too often patients question nothing and go along with whatever the doctor says because, well, they’re the doctor and they know everything. This is why direct access is so important. For this patient population, we are their best option and it should be up to us to decide whether or not they need an MRI or medication for their condition. But the problem is many patients feel the doctors’ opinion is superior to all others and the media feeds into this as well. Everyone feels the “doctor” will make the best decision and prescribe the best treatment. People believe everything they see on television and, unfortunately, everything on television is garbage. I don’t see why physical therapists couldn’t create a commercial highlighting these common statistics and emphasizing our treatment approach. I see commercials by physician groups all the time on how effective spinal surgeries are. Why shouldn’t we do this and what’s holding us back, besides the cost?
I have a 31 year old, very fit guy with mild symptoms of FAI bilaterally and very limited hip IR bilaterally, surprisingly greater on the uninvolved side. X-ray confirmed mild CAM deformities bilaterally. He appears incredibly stiff in the posterior capsule of both hips. I’ve been trying to mobilize his hips manually and with power bands as part of the HEP, but I feel like there’s no significant benefit thus far. I’m also not sure how much to expect to improve with someone with an anatomical variation such as a CAM deformity, whether it be a mild deformity or otherwise.
My PICO question for him is: Will a patient with femoroacetabular impingement benefit from manual joint mobilizations compared to a home exercise program.
The narrow search string with with the addition of “femoroacetabular impingement” came back with a surprising 12 results.
The expanded search showed 337 results.The narrow search results ranged from 2015 back to 2005, with 3 good hits discussing conservative management for a long distance runner, a case report for a HEP, and another discussing hip weakness in a patient with FAI. All I felt were applicable to my question. The remaining 9 addressed rehabilitation after surgery, still helpful.
The expanded search showed the first 20 results were from 2015 & 2016. A few results on the first page may be informative, discussing biomechanics during gait, strength, and hip kinematics with patients with FAI; however, most discussed objective findings rather than treatment.
I felt the two results were very different. Narrow was definitely more applicable to my question, but I think it may be worthwhile to do a quick scan with the expanded search stream if you want to find more “nice-to-know” information.
Hey Oksana – 15 secs was just an arbitrary hold time. I’ve been told it needs to be a noxious stimulus to a trigger point to reproduce and refer the symptoms. I’m sure 10 secs was fine
Oksana –
Femoral nerve tension testing is a good way to help with your diagnosis of meralgia paresthetica, as you said. I would also palpate the area to see if you could possibly manually compress the lateral femoral cutaneous nerve as well. Is she able to recall any position or activity she is in when she feels the numbness?Were you able to reproduce or exacerbate the lateral thigh pain/numbness? Did PA pressure to the lumbar segments change the symptoms in her thigh? Also, the glute min could refer pain to the lateral thigh. I would palpate and apply fair pressure to tender areas of the glute min and hold for maybe 15 secs or so, if tender, and see if that reproduces it.
The authors do a nice job of highlighting the fact that there is evidence to show pathology can be present without pain. I feel this is the discrepancy in the results. I say the reason the PT didn’t identify as many RC tears as the arthroscope did is because they weren’t symptomatic and there is a risk their operation will be on a structure that’s not even causing them pain. I would argue that knowing a pathology that is present will bias your treatment approach. We see this in the clinic all the time. For example, you may have seen a patient for an initial evaluation and the script from the MD reads “MRI reveals L5-S1 disc herniation, please eval and treat with extension exercises and core stabilization.” This doesn’t mean it’s symptomatic. Now I’m going into my eval with disc herniation in my mind, my judgement may be clouded and there’s a chance I could overlook other possibilities. O’Sullivan states in his 2005 paper on classification of CLBP, “even when a specific pathoanatomical diagnosis can
be made, there is still a need to classify the disorder based on the mechanism(s) that drive the pain disorder to ensure appropriate management.” As Nick stated, it’s nice to know precisely what structures are at fault and the pathology present to make predictions on healing and prognosis and to educate our patient’s, but our goal is to improve functional movement and our approach is based on symptom irritability. This is more challenging when a patient has been informed of abnormal imaging findings. Patient’s have an incredible desire to know exactly what’s wrong with them. When a patient feels pain, they need to know why. They don’t like to hear their therapist run through a list of possibilities and seem uncertain. They need to know what’s going on and what can be done about it. When their doctor can look at an image and say with certainty “this is what you have and I can fix it with surgery”, that’s very concrete and easy to conceptualize. However, this is the problem with healthcare. I feel patient’s would have much better outcomes with therapy if physicians stuck to just performing physical examinations because, as research shows, there is much better agreement between clinicians. I nice follow up study to this one would be to follow these patient’s after their operations and throughout therapy and recovery and perform another physical examination and history and compare the findings.Oksana- I mentioned the “T4 syndrome” because I essentially know nothing about it, I have read brief descriptions in things such as independent study courses the APTA has published. I wanted some input from others as to whether or not it should be considered, if anyone has seen a patient with neurogenic UE symptoms or whole arm and hand numbness that wasn’t thoracic outlet or cervical driven and if it is thought to exist in the first place. I had a patient last year that c/o bilateral UE whole arm and hand numbness that I could not explain despite testing everything I could think of and looking back I wondered if it were a possibility. You could ask your mentor their perspective, but don’t be surprised if they laugh at you ;)
I agree with you guys about the positioning of the patient’s. I also wanted to make note of the duration they spent on US. Seems there was a significant amount of time spent on STM addressing more global areas and the US was only applied to two small locations. If I were to implement US to achieve this goal, if I thought it would help, I would apply it to multiple tender points in a continuous fashion with the goal to heat the tissue to an adequate temperature to increase pliability (in theory). On a side note, I think it would be more applicable to study the differences in neural gliding vs STM. The disadvantage of using US is that it’s already shown to not be effective for much of it’s use. I hope by the end of our discussion to develop a better understanding of why they would use this modality for this study and not another intervention that has been shown to have some effect.
Thanks for the post Laura, seems complicated for sure. Nice choice.
Another diagnosis that comes to mind that I may have treated in the past but did not know it because it wasn’t on my radar, is T4 syndrome. I don’t believe there’s much research on the pathology, although I certainly need to do more investigation. With a complaint of “whole hand burning and numbness”, that’s something that comes to mind along with TOS, brachial plexus. Given the fact that his symptoms seem to change with thoracic mobility going from slumped posture to upright posture, perhaps the symptoms could be changing due to movement in the thoracic spine affecting the sympathetic chain. Again, I’m certainly no expert on this pathology, nor do I know if it would change, but I think it would be worth mobilizing the thoracic spine in a seated position with his arms crossed, cervical spine neutral and scapula supported and neutral to see if that changes his symptoms.If anyone notices anything about the subjective history of this case that would not make them think T4 syndrome, please let me know. Has anyone ever seen T4 syndrome?
Another test I may have added would be cervical distraction in extension after it produced symptoms, as well as testing in cervical extension quadrants to assess change, if you hadn’t done that.
As far as differential diagnosis of C/S radic, TOS and brachial plexus: I would refer to the suggestions of the C/S radic CPR looking at rotation, distraction, ULTT, and Spurling’s to rule that in or out first, as well as reproduction of symptoms with cervical mobility testing. Then I would move on to TOS, which doesn’t have the best test metrics. I’ll have to do some research on brachial plexus.
I’m going to move on to your article now. Thanks for the post!
Nice post Nick. To answer you last question, I recently assessed a friend complaining of anterior shoulder pain. She’s a swimmer and c/o pain reaching overhead at end range shoulder flexion. She demonstrated significant tenderness in her biceps tendon. I screened her C-spine and found she also had cervical tightness with rotation to the same side and stiffness in her lower cervical spine. Turns out she was super tight in her ipsilateral levator scap, weak in lower trap, limiting her scapular upward rotation causing her to impinge. She was also significantly hypomobile in the lower cervical and upper thoracic spine. Take home point is, even with localized shoulder pain it would be beneficial to pay closer attention to the lower cervical and upper thoracic spine, as I feel hypomobility in this region could adversely effect the mobility of the scapula, or vice versa