[Steven Lagasse]

1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?
Primary: Labral Pathology

Differentials:
– Myofascial / Cuff or biceps
– Impingement

2) Are there any objective tests you feel would provide a clearer picture of this case?
– Speed’s Test
– Palpation to RC mm
– Painful arc

3) Do the objective findings fit a clinical pattern? If so, of what?
Overall, yes the objective findings appear to fit the clinical pattern of labral pathology. Could also have a rotator cuff component.

4) What impairment or limitation would you want to address first with this patient?

Strengthening of the cuff and other stabilizing mm.

[Steven Lagasse]

1) Looking ONLY at the body chart, what is your primary hypothesis?

Primary hypothesis: Femoral nerve entrapment.

2) Looking at the body chart AND subjective exam, now what is your primary hypothesis? Next 2-3 differentials?

Primary hypothesis: Hip OA

Differentials:
1. Capsule
2. Myofascial – TFL/ITB, Hip flexors
3. Femoral nerve entrapment

3) What are some other questions you could have asked to help rule in/rule out your hypotheses?

– Does your hip pain come on with back-related movements? (bending, twisting, etc.)

– Does it feel like your hip has less motion compared to the other?

– Does your hip pain mostly subside 30 – 60 minutes after waking up and moving?

– Does snapping, popping, and/or locking occur?

– Does movement after sustained sedentary positions increase your symptoms?

4) Does the objective information/patient presentation make you think of a particular diagnosis?

I believe the objective information and patient presentation helps to rule-in hip OA

5) What would be your first thought on treatment for this patient?

I would likely attempt a low-grade distraction technique. If the patient tolerated this well, move into higher grades.

[Steven Lagasse]

This RCT checks off the boxes regarding a well-done study. Much can be appreciated regarding the exhaustive subjective and objective baseline testing, as well as the use of randomization, concealed allocation, and blinding (all but the treating therapists). Also, this study clearly stated their purpose and stuck to that purpose without attempting to push their agenda or misconstrue the data. It was also refreshing that the allocated treatment times were consistently matched for both groups.

I found it worthwhile that this study poked holes in my preferred treatment approach (a combination of manual and exercise therapy). After all, we, as clinicians, come with biases and preferred treatment approaches. It is not uncommon for these biases to become overly rigid. With that, although this study will not cause me to completely abandon my current method of treating, it does help remind me of the importance of carrying with me humility and a healthy sense of skepticism.

This study also brings to mind the importance of communicating with the patient. It is up to us to capture their insight and assure that our treatments align with their idea of therapy. If we fail to capitalize on patient buy-in or neglect to explain how our treatments will work to achieve their goals, then we’re likely missing the boat.

Taylor, I like your perspective, “Maybe we should take the role of an educator with these patients rather than trying to treat each one with an extensive protocol. We should focus on providing education about pain, osteoarthritis, prognosis, activity recommendations, etc. There’s a lot of information that we can provide this population to help them cope with their symptoms easier.”

Before we put our dirty paws on the patient, we should be spending an appropriate amount of time educating them, and helping them to achieve a clear understanding that wear-and-tear in a joint occurs as a normal byproduct of living.

[Steven Lagasse]

1) Reading only the subjective examination please list your primary hypothesis as well as your top 3 differentials
Primary Hypothesis:
Radic L3/4

Differentials
– Facet L3/4
– Femoral Nerve Entrapment
– Extra-articular hip

2) Does the objective information follow a familiar pattern? If so, what are your primary *’s? If not, what information is inconsistent?
Appears to fit a pattern for L3/4 Radic

Primary *’s
– Quad weakness
– Decreased DTRs
– N/T in a dermatomal pattern
– Repeated Extension decreasing pain/symptoms

3) What other objective tests would you have performed with this individual?
– Slump
– Ely’s
– Hip PAM
– Maybe Quadrant

4) Given the patient’s current presentation, what is the role of physical therapy in this case?

Capitalize on the fact that he is feeling better from the steroid pack. Focus on performing movements that continue to decrease his pain/symptoms. His goals are stair climbing, and yard work that requires flexion positions. Begin incorporating activities to help with quad strength and slowly start to weave in flexion based movements once they’re not too provocative.

[Steven Lagasse]

What resonated with me most were the few sentences about committing to an idea. I believe this parallels nicely with committing to the post-subjective and -objective hypothesis. This act of committing has been a portion in my examination that I have been honing in on, as it is easy to become wishy-washy. My worries of incorrectly hypothesizing have often led to more confusion than helpfulness, and as the video states, “If you don’t make a prediction, what you will learn from this will be no more than if you had never seen this at all”. By not committing, we lose out on our ability to clinically reason and develop pattern recognition. It is likely more important to realize that the information we have gathered is inconsistent with our hypothesis, rather than retrospectively attempting to make sense of it.

[Steven Lagasse]

Helen, thanks for this post. I appreciate your transparency. I have also struggled with this. In DPT school, we have three condensed years of learning, where we are exposed to an abundance of literature and ideas. Misconstruing certain evidence and/or remembering an idea incorrectly inevitably happens. I find posts like these worthwhile, as they work to keep us humble and in-tune with the information we say to our patients and colleagues. Thanks!

[Steven Lagasse]

1) Is there any more information you would have gathered during the subjective?

Quality of headaches and what triggers them (light vs. movement, etc.)
Is there an epicenter, or does one symptom appear to be causing the other symptoms?
How have these symptoms evolved over the month?
Was she the driver or passenger?
How soon after the MVA did symptoms come on?
What is her mentality regarding this accident?

Are there any other outcome measures you would have administered?

NDI, and perhaps something for depression. My clinic only uses FOTO so my experiencing with using other outcome measures is quite limited.

2) Based on body diagram and subjective exam is there anything else on your differential list?

It’s easy to think of an all-encompassing list when there’s plenty of time to reflect. Some additional differentials that I think might be warranted are…

Cervical Radiculopathy
Thoracic referral
1st rib
Scapular Dyskinesia
Ligamentous injury (Neck and/or shoulder)

Is there anything you would change on mine?
Is WAD appropriate to be on the differential? I feel like this is more of a treatment guideline regarding rather than a hypothesis. I could be wrong about this though.

3) Considering irritability would you have changed your objective exam? What would you have done differently?

Hard to say. For me, it depends on the patient’s affect, and demeanor. So long as they were tolerating the exam well and weren’t having pain with all tests/movements I would likely have continued.

Cervical Spine: In a perfect world I may have thought to perform the radic cluster, flexion with compression and if provocative, cervical distraction to see if that changed their scapular symptoms. Unweighting the shoulder girdle and performing cervical ROM. Neck flexor endurance testing may have also been helpful.

Shoulder: Perhaps some lag signs if the patient was able to tolerate them.

4) What is/are your primary hypothesis or hypotheses?

Maybe a cop-out answer but based on what we know at this point, this presents to me as a heightened system with a host of myofascial components. This is, however, contingent on how the radic cluster played out.

5) What would your PICO question be for this patient?

Manual therapy versus exercise for return to work in young adults post motor vehicle accident

[Steven Lagasse]

Anna:

Did all of the areas have the same aggravating and easing factors and could you/did you establish the relationship between all of them? Was there anything in particular that for sure aggravated all of the symptoms?

Great question – this will be addressed tomorrow. However, to give you an answer, no. I failed to map these. Reflecting on this, I should have been more comprehensive in asking which tests provoked which symptoms. I do not believe one test reproduced all symptoms.

You mentioned irritability was min-mod, could you elaborate on this?

This patient had a very low baseline level of pain, however, the evaluation quickly elevated those pain levels (5-7 / 10 on NPRS). After about a minute his pain would return to baseline. I felt this warranted min to mod irritability.

You touched on PAM being non-painful and AP “feeling good”; were there any limitations there?

AP to the right GHJ felt stiff compared to the contralateral side.

Some areas wereThere were areas that were TTP but did any of them specifically reproduce this patients pain?

Right periscapular musculature and upper trap

Thanks for the questions!

[Steven Lagasse]

A lot of great answers rolling in. Thanks, everyone!

Full disclosure, this is far from a perfect evaluation- there were questions left unasked, tests not performed, and body regions that were, unfortunately, neglected. Although you’ll all hear more about the case Saturday, might anyone have specific questions? I will do my best to provide answers!

[Steven Lagasse]

The patient is a 22-year-old male

My apologies for leaving this information out of the PDF!

[Steven Lagasse]

That was a humbling article. It did a great job of shedding light on the gaps in my current knowledge and clinical regarding peripheral nerve entrapment. I have found evaluating neurogenic pain (outside of radiculopathy) rather difficult. Unlike radiculopathy, there isn’t a very clear easily cluster. With that, I enjoyed being able to see the thought process and logical flow behind the clinician’s evaluation. I also enjoyed how their special questions drove their objective tests to rule out certain structures, and ultimately rule in supinator teres syndrome.

Although my logical flow and clinical reasoning are getting better, it is still something I struggle with regularly. Did anyone else have a similar feeling while reading this article?

[Steven Lagasse]

I am writing up a Clinical Reasoning Form on my TMD patient. My PICO question led me to this systematic review. It’s quite long but there is a short and sweet section regarding some of the current evidence (or lack thereof) on manual therapy and exercise therapy.

Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis

[Steven Lagasse]

Interesting case. I also had a recent TMD case. Thankfully this individual came in during my mentorship time with AJ. After looking at the script “TMJ Dysfunction” AJ stated, “TMD tends to be associated with cervical pain, and a host of biopsychosocial factors – I wouldn’t be surprised if she was anxious and catastrophizing.” Sure enough, the body chart showed cervical pain, and her PMHx had anxiety and depression checked off. You cleared out the cervical spine nicely. However, were you able to dive deeper into their depression? They’re being treated but is this treatment working for them? If they’re taking medication, is this medication helping them to manage their feelings/emotions?

[Steven Lagasse]

1) Yes, I feel the authors made conclusions regarding the primary purpose of the article. However, they did begin to make some leaps regarding biomarkers, biomechanical effects, and the rationale behind increased recruitment of the deep neck flexors. These topics went beyond the article’s purpose and began to sound like conjecture.

2) Relevant: ultrasound, stretching, TENS, and mobilizations are all backed by the CPG under the chronic stage.
Less Relevant: superficial thermal therapy and isometrics are not backed under specifically under the chronic stage in the CPG. I do believe isometrics would still be effective, especially if a patient is highly irritable.

3) The researchers did not specify the duration of treatment received by the control group versus the experimental group. The experimental group received an additional intervention. It may have been the case they also received a longer duration of treatment. If so, this could skew their results.

4) I spent roughly 60 minutes reviewing this article. I would invest a similar amount of time to find and read an article regarding contemporary treatment for a challenging patient. With my poor ability to scour the literature, I believe most of that time would be spent attempting to find a pertinent article. I need to work on getting better at this skill. However, I have found the PEDro website to be very helpful in finding more meaningful articles quickly.

[Steven Lagasse]

1.) Top 3 diagnoses based on subjective
-Cervicogenic HA
-Myofascial referral
-Spondylosis

2.) (+) on objective
-CFRT
-Upper C-spine CPA/UPA

3.) Top diagnosis after subjective and objective
-Cervicogenic HA
Why?
-Cervicogenic HA is my primary hypothesis because of the positive CFRT
Additionally, reproduction of symptoms with upper c-spine CPA/UPA also recreating his symptoms and are most comparable

4.) What HEP? What manual therapy?
HEP:
Supine cervical rotation on a pillow in symptom-free ROM
C1-C2 Snags (supine if not tolerate in sitting)

Manual Therapy:
C1/C2 CPA/UPA’s to tolerance; Grade I/II if unable to tolerate Grade III

5.) Something else?
-The fact that he is experiencing HA bilaterally does make me feel there may be another component to this. Potentially something myofascial in nature? I would enjoy seeing sitting vs. supine cervical rotation. I would also enjoy seeing how unweighting his shoulder girdle(s) affected his symptoms.
-The fact that this patient was seen by neuro and ENT allows me to feel more confident something nefarious is not looming

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