Forum Replies Created
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?”
A lot of great chatter. Seeing that the presentation is later today, let’s further the discussion during that time.
Good points, Helen.
My PICO was the following: “Is manual therapy effective for the treatment of neck pain with cervicogenic headache and/or cervicogenic dizziness? ”
I tend to use PEDro before using PubMed. The search string yielded 3 articles. As you said, this would normally tell me to make the search less specific. However, this RCT was rated 9/10 which caught my attention. Upon reading it, it applied to my patient quite nicely. I got lucky, to say the least!
- This reply was modified 2 months, 1 week ago by Steven Lagasse.
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.
- This reply was modified 4 months ago by Steven Lagasse.
1. Do you feel like my search strategy was too narrow to start with? Why or why not?
Your search strategy looks fine. The fact that you managed to only come up with 14 articles likely reflects that.
2. What are some strengths/weaknesses of this article?
For strengths, having some of the more revered researchers such as César Fernández-de-las-Peñas, and Emilio Puentedura is certainly a strength. The methodology of this RCT is strong. Further, the authors do not extrapolate their findings or make wild claims.
A primary weakness of this study is that the authors used a sample of convenience and only two treating therapists. As stated in the article, this can limit the clinical applicability and/or generalizability of the findings. Also, although it may not be a weakness, I did find it interesting that the authors excluded those individuals who had received prior manipulation. It has been my experience that patients with cervical spine symptoms have already seen a chiropractor before seeing physical therapy. Thus, the majority of my patients have already received some form of manipulation before seeing me. I am curious to know the authors’ rationale.
3. Do you feel like this article impacts or changes your clinical practice for an individual that “fits” into this category?
My take away from this article is that, if a clinician is going to go for the throat with cervical manipulation (pun intended), then they may as well back that up with those thoracic manipulations that have been proven safer. Although this may not more readily improve their perceived pain, the article did show for it to improve their perceived level of disability. I believe reframing a patient’s beliefs regarding disability to be quite impactful, especially on a biopsychosocial level. The less disabled the patient feels, the more they will likely do. Changing the patient’s beliefs may create an upward spiral and expedite their rehab. This also leaves me reflecting on the idea of treating manipulation as “input to the system” rather than treating a biomechanical issue.
This video brings to mind a specific patient encounter that I had with a student. During an examination, the patient was complaining of unilateral low back pain. She identified her pain by pointing at her right SIJ aka Fortin Finger Sign. The patient’s subjective examination also fit SIJ dysfunction. Working in a system 1 fashion, I explained to the student my prediction of SIJ dysfunction and that an SIJ cluster would likely be positive.
Moving into the objective exam, lumbar active and passive ROM was negative. I had yet to reproduce symptoms, however, thinking fast, I decided to skip lumbar quadrants and move right to the SIJ. The cluster was negative across the board. My prediction was dead wrong. This quickly made me snap into system 2 thinking. I moved back to the lumbar spine and performed a more rigorous exam, to which a back right lumbar quadrant reproduced the patient’s familiar symptoms. What was initially an SIJ dysfunction became lumbar facet – the rest of the exam went smoothly.
After the encounter, my student and I spent time reflecting. This experience allowed for a nice discussion regarding systems 1 and 2 thinking, as well as the importance of making predictions, committing to a hypothesis, and performing a thorough examination. Further, the importance of not being afraid to go back to your differential list when the signs and symptoms are no longer matching your prediction/hypothesis.April 23, 2020 at 6:38 pm in reply to: Its Time to Put Special Tests for RC Related Shoulder Pain Out to Pasture #8546
Helen, a question concerning your below quote-
“For example, I may think “this shoulder does not like compression” with the crank test or “this shoulder does not like internal rotation” with Hawkins Kennedy.”
Does the shoulder truly not like internal rotation? Or does it not like internal rotation when combined with horizontal adduction. If the latter, why? And is it important we differentiate this? The same logic applies to the crank test. During the test, do those specific ranges of motion that reproduce the patient’s symptoms matter?
April 21, 2020 at 5:06 pm in reply to: Its Time to Put Special Tests for RC Related Shoulder Pain Out to Pasture #8535
- This reply was modified 5 months ago by Steven Lagasse.
Barrett answered your question on using special testing as an objective asterisk quite nicely. I agree with his thoughts.
Regarding your question on whether or not this article changes my thoughts on special questions – I’m unsure. At best, it reminds me where special tests stand in the clinical examination hierarchy- closer to the bottom rather than the top.
I did resonate with your quote below and felt I would speak to it:
“I feel like my pattern recognition is based a lot more on specific subjective complaints, functional assessment, ROM, and resisted testing with less of an emphasis on special testing. To be honest at times I feel like I am just doing it because that is what we learned but don’t put a whole lot of stock into the findings…”
Regarding shoulder special tests, beyond impingement and instability, I too feel as though I perform these tests for the sheer sake of doing. This type of practice has not been helpful. I have brought this to AJ’s attention during mentorship sessions. He will force me to reflect, asking questions such as: Why do you think the test isn’t helpful? Do you understand the test and/or know what it is assessing for? From there it’s back off to the drawing board. This requires a fair amount of humility but has been quite helpful in progressing me from blindly doing to actively interpreting. This is still something I work on daily. Perhaps this insight will be helpful. You’re certainly not alone!
1) When trying to find an article, a specific PICO question is most important. Once I come to my PICO, I’ll enter that into PEDro for their rigorous ranking system. However, PEDro can be fickle, so if I’m not getting what I want I’ll try Pubmed. I have found using synonymous words, and the use of “AND” and/or “OR” quite useful. If I find an article on Pubmed, I’ll then look it up on PEDro as well to get a sense of its strength. There is no perfect system, but a strong PICO certainly sets you up for success. I’ll also read some abstracts and make sure the article speaks to what I am looking for, whether it fits my bias or not.
2) As Taylor said, the exercise selection, overall, is nonfunctional. This comes with the territory of “stabilization.” Both treatment groups are missing patient-specific exercises. Although appropriate for the purpose of this study and generalizability, it certainly isn’t helpful in terms of returning a patient to their baseline function.
3) Agreed with the above opinions. Hard to say that these EMG findings can be directly correlated to decreases in pain and improved function. Also, how sure can we be that the appropriate deep trunk musculature is being assessed by transcutaneous EMG? Hard to know for sure.
4) What is interesting, is all three groups utilized some form of core stabilization. However, both experimental groups improved significantly while the control group did not. The argument here can be that the experimental groups were more specific and thus demonstrated greater improvement. Conversely, both experimental groups were not all that patient-specific. This may instead support an argument that the more involved we therapists are in the treatment sessions (i.e. manual therapy, education, touch, etc.) the better our outcomes. The way I see it, the therapist is inevitably more involved via manual and verbal cues during a manually resisted isometric exercise or PNF pattern versus having the patient independently perform a supine curl-up. Thoughts?
Similar to Helen, I’ve yet to see many wrist/hand patients. My reply to this discussion is based on the two provided articles and Reiman’s Orthopedic Clinical Examination text.
– Does your wrist feel unstable?
– What activities cause swelling?
– Is gripping painful?
– Are you experiencing numbness and/or tingling?
– Is this getter better, worse, or staying the same?
– Nocturnal Symptoms?
– AROM, PROM, RROM
– Various grip strength testing
– Accessory motions
– Special Testing per article
– Kienbock’s disease
– Superficial distal RU ligament sprain
– Deep distal RU ligament sprain
– Ulnocarpal impact syndrome
I would have the patient pursue imaging if their symptoms were gradually worsening, were inconsistent with the examination, or worst at night with reduced activity
Taylor, there a lot of ideas and moving parts in this discussion. It looks like you undoubtedly have more ideas in your head now. Perhaps take a step back, digest some of this, and make a plan for the next visit?
The patient’s symptoms appear to be bouncing back and forth from shoulder to elbow. The patient also demonstrates grip weakness. With this information, do you feel a cervical radiculopathy cluster is warranted? If negative, perhaps spend more time ruling-out at the shoulder and elbow rather than ruling-in?
After all, as Eric said, concomitant pathology in the shoulder makes things ambiguous. Perhaps if you rule-out additional competing differentials using those test clusters we’ve spoken of in the OMPTS courses, the culprit will begin to surface on its own. Even if this is not the case, it can clear up some of the ambiguity, and allow you to begin treating with more clarity.
Hopefully I’m not merely stating what is already obvious.. *insert cold sweat emoji*
- This reply was modified 6 months ago by Steven Lagasse.
– Cervical Radic C4/5; C5/6
– Rotator cuff referral (Infraspinatus)
– What position was your arm in when you were bumped?
– Is this getting better, worse or has it plateaued?
– Is the location of your symptoms specific or vague and diffuse?
– Does your arm ever feel unstable and/or do you feel apprehensive with certain shoulder positions?
– Do any shoulder movements and/or positions provide you with relief?
– Screen: cervical, shoulder, and elbow
– Radic Cluster
– RC mm testing: MMT’s: full can and ER; Lag signs
– Impingement: Hawkin’s Kennedy, painful arc, SAT, SRT
– Labral testing based on arm position when injured and feeling of instability (cocking phase vs. traction vs. compression)