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Taylor and Anna, I agree with you both.
Taylor, I like your thinking about dizziness. What do you think about the potential for an ocular trigger to her symptoms? I feel it would be interesting to investigate interventions such as tracking and convergence. I recently had a patient who was status post TBI. She had a reproduction of her headaches and symptoms of nausea with solely tracking exercises (seated without head movements).
Since this patient is having neck pain, I would want to get her back to tolerating cervical motions. Starting supine, we could work on STM and PROM into the cardinal planes. If tolerated, we could move onto AROM and performing joint position error testing.
The focus of this visit should be to screen for additional red flags and other plausible explanations. The most glaring would be cauda equina syndrome. I believe urinary retention yields the highest positive likelihood ratio, followed by saddle paresthesia – it appears this patient has both. Screening for bilateral leg pain, multi-segmental weakness, sensory loss, hyporeflexia, and/or subjective sexual dysfunction are all warranted (per the VOMPTI slides).
Post-screening, I would educate this patient on the matter and strongly recommend she seek care immediately (assuming nothing else added up). I would also attempt to call her PCP with the patient in the room. Hopefully, this would expedite her receiving care and/or shed light on the situation regarding other plausible reasons for these symptoms.
I find it perplexing that the patient’s OBGYN did not feel this was more urgent and send her to the emergency room. I understand frightening a patient is not always beneficial. However, if there is a time to scare someone, this may be that time. After all, I wouldn’t want to be the clinician who misses a more sinister pathology and leaves a patient with potential permanent deficits in urogenital function.
Kyle,
I’m unaware of specific guidelines to help me in ruling in a fracture similar to that of Ottawa knee/ankle rules.
I believe the more classic signs/symptoms would be pain at rest/night, fracture quality pain with palpation, unwillingness to perform AROM (pronation/supination), exquisite pain with PROM (pronation/supination), etc. Are there specific guidelines that you’ve come by?
I feel age does play a role. With the pediatric population having more difficulty with communication, especially a 9 year old, I feel playing cautious is the best bet. With that I would likely refer back to the PCP and see if he/she feels xrays are warranted.
This article serves as a good reminder of how much goes into healing. The article reminds me of Lorimer Moseley’s iceberg analogy. I feel the overwhelming detail in this article is analogous to the portion of the iceberg that is underwater. This information is beneficial to know. However, more importantly, is the portion of the iceberg above water – the part we should share and educate our patients on. With that, I felt relearning many of the modifiable risk factors that play a role in tissue healing most beneficial. Further, this is likely where clinicians can immediately work to begin changing their practice by providing thorough patient education.
One concept that stood out to me was the effects of opioid use on tissue healing. This modifiable risk factor was more foreign to me. I’m curious to know if it was new to anyone else?
The large portion of the patient demographic that I see are post-surgical. Nearly all of these patients are age 50+ with several comorbidities such as diabetes, obesity, not to mention tobacco users. It would seem that placing these comorbidity-riddled post-surgical patients on opioids to be a contraindication. However, it is something that I see quite frequently. Clearly, opioids work well post-op to void pain. However, at what point do the cons outweigh the pros?
I feel my practice has improved most in terms of moving away from merely doing and more towards understanding the “why”. Coming into the residency, I felt confident gathering information but had trouble piecing all of that information together. After an evaluation, I often left the treatment room feeling overwhelmed, and still had two to three competing diagnoses on the table.
I believe a reason for this was due to neglecting the subjective examination and not asking special questions to help rank my differentials. This would often lead to over testing and becoming frustrated and confused during the objective exam.
With my subjective exam being far more purposeful, the objective examination has become streamlined. This has helped to improve my clinical reasoning and allows me to feel confidence coming to a diagnosis.
Subjective:
– Further questioning about the fall: FOOSH vs. direct impact on elbow/wrist; was she skiing at a fast speed or slow?
– Past medical history, specifically wanting to know of any possible MSK diagnoses that may move fracture higher up the differential list.
– Attempting to inquire if the patient is having pain or is just scared of experiencing potential pain.
– Was there a previous elbow/wrist injury that was worsened by this fall? And/or prior fractures?Objective:
Start with AROM and, if tolerated, then move into passive and resisted ROM. I may then move to palpating between extremities (if tolerated), asking if pressure felt different between sides at common fracture sites.I agree with Anna regarding the patient’s age. It could be the case that a direct line of questioning may not be as helpful. I feel this patient would require a more slow and deliberate examination. Depending on the patient’s affect, I may also opt for a less detailed, so the patient does not feel I am trying to inflict pain. Establishing rapport quickly may also be helpful i.e. making the patient laugh, performing the tests/measures on her parent first, etc.
Helen, a lot of great points. I resonate with your idea of sending out feeler questions then moving to more and more direct questioning. As you said, the lack of enthusiasm may be related to something non-MSK. For all we know, may the patient’s dog just died, or they’re in a fight with their best friend who also plays the same sport. The ability to poke and prod will depend on your rapport with that patient.
If attempts to gather information fall short, I would then look to involving the parent. However, this can indeed be tricky. Some parents overstep their boundaries, while others have nothing useful to say at all.
Finally, I like what you mentioned about therapist reflection. Perhaps the patient is being overloaded, and therapy needs tapering, or maybe therapy has become stale from doing similar exercises. The variables go on..
If this were a 24-year-old adult, I would have the conversation and be direct. “Hey, how’s everything going? I’ve noticed that you seem less enthusiastic about therapy. Is something wrong? How can I help?”
This patient case speaks to the importance of making predictions. With the information given on the patient, extension based sensitivity, and/or positive neuro findings would be on my radar. Failure to reproduce the patient’s symptoms in this manner would directly challenge my prediction, and raise my suspicions that something non-MSK was afoot. This may lead to increasing the rigor of my examination, pivoting to another item on my list of differentials, or reaching out to the PCP.
As for pharmacology, I would agree that much is forgotten after PT school. The best way to improve upon this is exposure. However, I believe it may be more important to focus broadly, rather than on minutia. After all, we are MSK specialists, not pharm/medical specialists. This paper serves as an excellent example. Although it provides the reader with a wealth of information, much of that information goes beyond what is essential to know. Simply being aware that statins can cause myopathy may be enough to justify a call to the patient’s PCP about something non-MSK and inquiry about their statin drugs.
1.) For this patient, I would focus on education about natural history and that patients with Bell’s Palsy tend to get better with time. Beyond education, working to improve any limitations found due to disuse would be my primary aim. Although many of the studies in the systematic review were not great, they do point to some possibility of exercise therapy being helpful. Providing this patient with a series of facial exercises would be a safe and worthwhile HEP. I’m under the impression that Bell’s Palsy caries with it stress, anxiety, and depression. Providing the patient with a sense of control via exercise may work to quell some of these negative emotions
2.) With such a dearth of information, a systematic review may be less helpful. I immediately think back to the concept “n of 1”. Therefore, if unsatisfied with the systematic review, I would move to RCTs to glean more information. Also, when reading a Cochrane review, I think it’s important to consider that their conclusions often results in the need for additional research. This is not always helpful and can cause clinicians to throw the baby out with the bathwater. For example, Cochrane’s review of spinal manipulation for low back pain (acute and chronic) is that it is no better than other therapies and/or modalities. However, there is a litany of RCTs stating that, although it might not be the magic bullet, spinal manipulation may certainly be a piece of the puzzle. I believe the same applies to physical therapy for Bell’s Palsy.
3.) After addressing education, I would focus on a “treat what you see” approach. Your exam showed myofascial restrictions, decreased ROM, and strength deficits. Safely treat those areas based on the best available evidence, even if that evidence is limited. Hopefully, those treatments will work to assist in this individual’s natural history. They’ll likely get better on their own, but perhaps we can expedite the process.
A lot of interesting points here. I would subscribe to the idea of using the PTQ in place of or combined with the NPRS would work well when setting expectations. Also, I believe this tool could also be helpful during the evaluation when deciding whether to reproduce symptoms or focus solely on symptoms mitigation.
Barrett, I have used pain as an assess/treat/reassess parameter. However, I found this works best with only those patients who are health literate. I also attempt to qualify this with the statement that we’re looking for an evident or fairly dramatic change in subjective symptoms. Having the patient attempt to distinguish between whether their symptoms decreased from 4 to 3 (or vice-versa) is not all that helpful. Anyway, I would agree with you, far better to anchor parameters to an objective measure.
Trying to dial into a pathology with only 1 to 2 questions is challenging. Adding the fact that this patient has obvious yellow flags makes the task even more challenging. Under these constraints, I would ask the following:
The first question I would ask is if she notices a reproduction in her symptoms with motions local to the cervical spine. This would begin to help rule-in or rule-out an upper cervical component.
Assuming the first question “ruled-out” the cervical spine, my next question would be to dive deeper into what specifically causes and/or reproduces her symptoms. I would want to know if it was the actual popping or the act of engaging the joint and adjacent musculature (without a pop) which reproduced her symptoms. This would allow me to begin differentiating between joint and/or myofascial pathology versus pathology of the disk.
Regarding management, I think yellow flags need to be addressed first. I would plan to start globally and, over time, become more narrow in my approach, focusing on the local impairments. The two patient’s I’ve treated with pain local to the TMJ benefited a great deal from education and reassurance. These individuals came in with poor beliefs. For example, one patient believed their jaw was disintegrating and breaking down the more they open/closed their mouths. With that, I believe education regarding the fact that movement, although currently painful, is overall safe, to be helpful. Secondly, it has also been my experience that many of these individuals went from living a normal lifestyle to becoming extremely sedentary due to the severity of their symptoms. Therefore, encouraging basic exercises such as returning to low-grade aerobic exercise and normal duties is helpful. I feel that would be the best/safest place to start given the limited information regarding this patient.