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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.
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.
Subjective Questioning:
– 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?Objective Testing:
– AROM, PROM, RROM
– Various grip strength testing
– Accessory motions
– Palpation
– Special Testing per articleDifferential List:
– TFCC
– Kienbock’s disease
– Superficial distal RU ligament sprain
– Deep distal RU ligament sprain
– Ulnocarpal impact syndromeImaging:
I would have the patient pursue imaging if their symptoms were gradually worsening, were inconsistent with the examination, or worst at night with reduced activityTaylor, 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*
Differentials:
– Cervical Radic C4/5; C5/6
– Labral
– Impingement
– Rotator cuff referral (Infraspinatus)Additional Questions:
– 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?Objective Testing:
– 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)-The focus on neuroanatomy was captivating and made me aware that this area warrants a continual review. I’m currently having flashbacks to Lauren’s OMPTS case presentation and the Saphenous nerve. Yikes. Moving forward, I plan to give these structures more weight when practicing in the clinic.
– I treat minimal to no patients who are looking to return to running. Thus, I have little experience with this population. It was nice to receive an in-depth overview of these individuals. I liked how Chris Johnson employed the idea of a minimalist approach when working with these patients. For example, rather than attempting to tearing apart someone’s running gait, it is likely the case that the patient needs a 5-10% increase in cadence.
I am currently practicing at SMH. Here, patients often present with similar surgeries. However, it isn’t uncommon to receive varying post-op protocols. This is likely due to the various medical institutions that offer these procedures, and nuances of the doctor. For example, it is often the case where a patient from UVA is referred with concomitant biceps tenodesis post rotator cuff repair. Additionally, the extent of the patient’s pathology, as well as comorbidities, may warrant a surgery that is more or less invasive.
I believe the patient’s comorbidities play a large factor when progressing them through a post-op protocol. In a tissue healing sense, factors such as diabetes and smoking will work to impede recovery. Further, the mental state of the individual can also curtail progress, where patients who are anxious or depressed may be less adherent in performing their HEP. Taking these factors into consideration can allow the therapist to accelerate or slow down the protocol based on the needs of the patient.
As Anna said, protocols are good guidelines to help make decisions. However, they should not undermine the therapist’s clinical reasoning.
1) What do you think about my search strategy? Tips/pointers that you’ve found helpful for other literature searches?
I thought you did well with the platforms you chose and your search strategies. My go-to platforms also tend to be PubMed and PEDro. Similar to the way Aaron describes the fiddle factor for manual therapy treatment, I feel the same applies to search strategies. Minor changes can create positive results. I have found using abbreviations, acronyms, and synonyms to be rather helpful. Perhaps utilizing “SMT” or, seeing you use a chiropractic article, “spinal adjustment” could have brought about more results. Just a few thoughts.
2) Read through my summary and the article, then let’s talk about statistics:
– What do you think about their findings in the results section?As far as I can tell, the authors were open and honest with their results. They did not appear to attempt to embellish their findings or make nonsensical leaps regarding the information obtained. It appears they were well aware of the limitations of their study and findings.
– Did they draw appropriate conclusions based on the statistics?
Yes, the stats seem fairly straight forward. There were a fair amount of limitations but the authors acknowledged this. The study would, however, benefit from additional blinding.
– What are your thoughts on statistically significant vs clinically significant?
In regards to this article, I do not feel clinically significant plays a role. With the lack of subjects, it is difficult to believe that their clinically significant findings hold much water. However, I do feel that it may warrant additional research. On the contrary, if I had a patient who I felt met the criteria for this article, and manipulation appeared safe, I could likely bias myself into performing a manipulation and see how the patient responds.
3) Any other general opinions on the article?
I am in agreement with Anna. Quite curious how they measured “naivety” to placebo treatments.
1. Based on the body chart and subjective, what is your primary hypothesis and top 2-3 differentials?
Primary: Patellar Tendinopathy
Differentials: PFPS, myofascial (quadriceps, pes anserine referral, adductor), Tibial Plateau stress fracture
2. With the subjective and objective information, does this patient fit a clinical pattern?
This patient fits a similar clinical pattern for PFPS and/or patellar tendinopathy. Both pathologies have similar presentations and symptoms: Pain with squatting, stair climbing, and long-duration sitting, along with biomechanical faults. The tenderness to palpation of the patella tendon and lack of pain with patellar accessory motions allows me to be more partial to this patient fitting more of a tendinopathy pattern.
3. Do you feel like you need more subjective/objective information for this case, and if so, what?
Additional PFPS testing: Q-angle, patellar tilt test, patellar apprehension test, and compression test.
Additionally, I would like to know is this pain superficial or deep? And where on the patellar tendon the patient is painful. Is it specific to the inferior pole of the patella or is it in the mid-substance? Also, what information was gathered from AROM vs. RROM? Something that may bias PFPS is isotonic contractions potentially being more problematic due to movement of the patella in the trochlea. On the contrary, if RROM elicits the patient’s chief complaint of pain then perhaps the tendon is the culprit.
4. What is your treatment for day 1 and what are you reassessing next visit?
Near pain-free knee extension isometric contractions. If tolerated well can perform pain-free isotonics (i.e. LAQ). Reassess the subject * that most closely reproduce their chief complaint.
1) Looking at the body chart, what is your main hypothesis and 1-2 differential diagnoses?
Primary: Cervical Facet
Differentials: myofascial (suboccipitals, upper trap)
2) Now utilizing the subjective information provided, does your primary hypothesis change? If so what is your primary hypothesis and differentials?
Primary: WAD
Differentials: Cervical facet referral, upper c-spine pathology
3) After reading the objective findings, is there a specific pattern forming which can help rule in/rule out some of the differentials? Which information seems to lead towards your hypothesis?
Tough to say, I feel more questioning is warranted. If a pattern is emerging I believe it may be a cervical facet referral.
4) What else would you have asked in the subjective and/or what other testing would you have performed?
Additional Questioning
-Numbness and tingling?
-Headaches?
-Is this getting better, worse or staying the same?
-Cranial nerve questions
-Symptoms referring elsewhere?
-What position do you sleep in?
-Time to AGG time to ease?Additional Testing
-Canadian C-spine rules
-CRFT
-DNF endurance
-Upper c-spine screening: nodding vs. rotationThis article highlights the importance of clinicians carrying with them a healthy sense of skepticism and to continually challenge their own beliefs. Additionally, it is articles like this that hopefully helps clinicians to take a step back, reflect, and make the necessary changes to their practice.
In reflection, I have found myself guilty of practicing many of the tests and measures, and nocebo infested remarks within this article. Although this isn’t necessarily wrong or bad, it is important to remain open-minded and to keep one’s practice plastic and ready for change, rather than being married to an ideology.
When working with future patients with SIJ dysfunction I feel my practice will benefit from moving away from pathoanatomic and biomechanical diagnoses. Instead, a focus on dispelling harmful beliefs, reinforcing resilience, and decreasing tissue sensitivity via load management will be most helpful.
Based on this study, I am uncertain I would forego the test-retest model. Coming into residency, the utilization of a test-retest model was somewhat new to me. My initial approach was to identify a problem list and treat those impairments biomechanically. Although fond of this approach, I was commonly left feeling unsure if my interventions were meaningful. The incorporation of a test-retest model has served me well in assuring that my biomechanical treatments were meaningful to both me and the patient.
Removing this model from my practice would leave me with the question, “And replace it with what?” Ultimately, I feel this act would do more harm than good. Anytime someone removes a belief system, ideology, or this case a treatment model, they are left with less than they once had. The scaffolding that had once served them has been torn down- something inevitably needs to fill that void.
Although this article does a good job of pointing out that there may be holes in the test-retest model, I’m sure this would be true with nearly all models. Our due diligence comes in the form of being cognizant that our approaches are imperfect. It is up to the clinician to remain eclectic, adjusting and adapting as needed, especially when an approach or model is no longer serving us and/or the patient.