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Great article Katie.
Here is another article that I believe was presented to the 2015 residency class. At the end there is a set of search strings that you can copy and paste to find more PT specific results, or looking for specific PT techniques.
Hi everyone,
I showed this thread to our Women’s Health Specialist, and here was her reply.“It does seem like maybe some of his (+) findings for LBP and SIJ may be secondary, compensatory patterns for PFMD. Neuralgia is certainly a good thought, except nerve pain tends to not ease quickly. Sounds to me like classic male pelvic floor muscle dysfunction likely picking up a little pudendal nerve either at levator ani or obturator internus. I’d be curious to know about hamstring tension, SLR findings and fascial restrictions. Pudendal neuralgia is often provoked with hip flexion past 90 with or without ER. I wonder if he gets any rectal pain or ever feels fullness like he is sitting on a ball. Fasical assessment? Hyper- or hypomobility testing throughout? Again, many findings to me scream PFM overactivity, I’d refer this guy to a pelvic floor PT for further assessment and consider co-treating! ”
Hope that helps!
It’s all in the show!
I like the idea they present that the “show” could be a priming or placebo effect that then enhances the actual effect of MT, much like that currently being studied in enhanced rehab results after transcranial direct current stimulation, repeated transcranial magnetic stimulation, intermittent hypoxia, and ischemic conditioning.
I try not to bias my patient’s results when i re-assess by saying “did that make it worse” or just “better, worse, or the same?”. I will often say, in a joking way “Now, don’t lie to me! You can tell me if it’s the same, it still helps us in our diagnosis”
I think I get a more accurate response after that.
Similar to Erik, I’ve had two patients who have received PRP injections. One was for patellar tendinopathy and the patient had a very poor outcome, probably made her worse. However, she had a significant history of 5 different surgeries for her knee, lots of arthritis, lateral meniscus tear, in pain for many years, and had concurrent stem cell injections as well. So that was a very mixed bag.
The other patient had low grade rib pain due to instability and it really helped him with a serious of injections.
Take it for what its worth!
Interesting Read. This reminds me of something during my final clinical rotation at the UIC orthopedic residency.
One of the residents was doing a research project about shoulder evaluation and special tests. Basically, You had to have your computer with you during a shoulder evaluation, and answer 3-4 questions after the subjective portion, then the objective portion.
If you answered “yes” to the question “Did you use special tests during your exam?” It would ask you if you were more confident or less confident in your diagnosis after performing the special test. A very high percentage of therapists were more confident in their diagnosis, despite the metrics on special testing in the shoulder being relatively poor.
I think that through the course series I gained a bit more of an understanding of which tests are relatively specific, and which ones are relatively sensitive, and I try to use the sensitive ones early in exam to help my reasoning and rule out things, and specific ones later in the exam after I’ve done the rest of my testing to help confirm a diagnosis.
After reading this article, however, it makes me re-think the utility and metrics of some of these tests and whether or not I bias myself with them.
Yeah, great article. I love the description of the special tests, and ideas for treatment.
I think the real gem of this article is table 3, which shows a bunch of activity variables for proprioceptive balance training. I usually have the typical eyes open/closed, standing on unstable surface, with and without other extremity movements. This table has other great ideas like doing these training exercises in dorsiflexed or plantarflexed position, and also changing head position during the exercise. I rarely use these variables, and it would be great to use them more.
Pretty cool taping technique at the bottom, but I have little confidence I could complete that tape job correctly in less than an hour.
1) Really great article. I like the treatments they chose, and it shows the CNS influence on orofacial pain. I am curious as to the rationale for using a C5 CPA for 9 minutes. Was this to mainly elicit CNS inhibitory mechanisms, or was this an attempt to change dysfunctional posture/biomechanics of poor upper cervical posture. My guess is the former, but I think hearing the authors’ rationale would be very interesting.
2) Personally I have used soft tissue work and inhibitive pressure. I have also referred some of these patients for dry needling with good results. As Erik said, I also have treated the cervical spine in all of my TMJ patients. The main TMJ directed technique I have used is a CAM glide ( Caudal, anterior, medial).
3) As far as resources, the two Shaffer articles from 2014 that were given to use as part of the VOMPTI weekend 1 cervical course have been my bible.
4) At the very least, if the patient hasn’t seen an ENT doc, I would refer them for exam. Wouldn’t want to miss something big. Same questions as erik, can you change any of the ear pain with manual techniques? I have a patient that has primarily tinnitus and not pain in his ear which can be changed with upper cervical techniques, by I have not had anyone with primarily deep ear pain.
Did the patient have any other the other symptoms of CRPS like changes in hair growth, sweating, skin texture changes, skin temperature changes?
1. One patient with highly questionable CRPS currently, as noted in the “all brains on deck” post. I also had one mid 20’s female patient during my final clinical rotation, again highly questionable CRPS diagnosis as no skin or trophic changes, more likely just chronic shoulder pain. This patient benefited from the recognise app, mirror therapy, meditation, and long sit slump neurodynamics. Patient had immediate sweating response and increase in body temp when we did long sit slump with thoracic rotation exercises.
2. With poise. My fiance is a pediatric PT so she can probably give a lot more information re: dealing with parents. You have to sell both mom and child on your treatments. some 17 year olds are nearly full adults and will be IND with HEP, others are still very much children and won’t do anything. I think this is a tough situation as you need to discern a lot about the child/parent relationship. Is mom being overprotective and exacerbating the emotional problems?
3. As quickly as possible. I would try to get the doctor on the phone and advocate for psych referral, and possible medications like sympathetic nervous system blocking agents, or neurontin/gabapentin maybe? previous cases have also been treated with antidepressents
4. Seems plausible to me. As Eric Magrum once said, it’s all about the re-assess. If it works, keep doing it. Scoliosis could effect sympathetic chain, but might change your ideas for manipulation if her scoliosis is too severe.
1. What are your general thoughts on the study?
N=9, so take that for what it’s worth. I loved that the authors were able to visually demonstrate the difference in brain processing with the BOLD response graphs (they look like onions). Further evidence that we can show people the problem is also in the central nervous system, and not just painful tissue. As August said, these patients had few comorbidities and no psychological diagnosis. You can take this as a pro or con. Pro: these patients might have “true” fibromyalgia, and give a clearer picture of the disease. Con: not generalizeable, and not an accurate picture of a more typical FM patient with depression/anxiety. Would love to see this study re-done with just people with depression, or just anxiety, and see if the results differ!
2. This article seems like a great way to sell it to that hesitant patient. We all know looks at you like you are an alien when you ask them to try to do 10 minutes on the bike at level 6/10 intensity. Might be able to say well in this study they did 25 minutes, that’s our goal!
3. I am constantly changing how I attempt to do this with patients. It’s so individualized. As August said, asking questions to identify stage of change is key. Find their motivation. Develop their trust in you. Develop their confidence in themselves. Small steps.
4. I rarely see what you described, which is a patient who is here for XYZ pain/injury, who doesn’t relate it to their fibromyalgia diagnosis. I feel most of the time I see a patient who states this injury is worse because of the fibro. I first see if this person’s clinical presentation fits with their subjective/objective measures. If so, I often think about the state of their central nervous system and how it could reach to my wording about their injury and prognosis and may deliver my evaluation results a bit differently. If I see fibro on the intake form I always ask about it, and that leads me in the right direction. When were you diagnosed…how are you managing…what do you know about the disease… asking the right questions can help you determine how you are going to incorporate that diagnosis into your treatment and plan!
1) General thoughts on this study, its design, and its findings.
No manual therapy included. (GASP!)
Ineligible if you were immobilized – *Personal anecdote trigger warning* – I had a bad ankle sprain that actually resulted in a tibial osteochondral defect. I received terrible PCP care and received no education regarding immobilization, bracing, weightbearing, etc. I didn’t present to an ER, as in the study, but what are the odds the ER doctor is up to date on ankle sprain guidelines, vs a PCP, vs DPTs? I honestly don’t know the answer.
very high number of people did not participate in the study. (maybe if you were not very injured you’d say…hey why not participate? And if you were more badly injured and in pain you were more likely to tell the researcher to “buzz off!”)
2) What are your thoughts about the PT intervention provided and the frequency and duration of care?
PT interventions seemed solid except for not having manual therapy. They don’t start proprioceptive training until the final stage of their treatment, whereas I would like to start as early as possible.
3) What is your typical PoC for patients with a “simple” ankle sprain?
My POC is likely to change after reading this. Unless the patient is an athlete and trying to return to sport faster, or has a physically demanding job where their ankle is limiting them, I will likely decrease frequency of visits and do more education, basic proprioception, LE NM control drills, and manual therapy.
I think the data in the article “trend toward” getting better a bit faster with PT, but no difference overall at 6 months.
I think that this article does make me think about ankle sprains a bit more like the Hip OA article Justin did his journal club on. There are probably a group of people who need minimal PT and I should try to identify those. Others will need more due to occupational demands, psychosocial factors.
4) What would you tell a patient that has been referred to you and tells you that they do not think they will get better because they read they wouldn’t in the New York Times?
I would say “that’s not what the article says! It says 60% of people have an excellent recovery if they do nothing. You are here in my office and are motivated to get better, so I think you will do better.”
NM control: lunges with rotation. Thoracic/lumbar rotation I’m assuming? just wanted to clarify this exercise.
Where did the patient feel her pain with the slump test. Feeling it in the back/buttock vs posterior knee would lead to different clinical reasoning.Is her R Low lumbar pain her same pain as she has had over the past 25 years, or is this new onset of lumbar pain since the knee injury?
1)Any other exam techniques you would have performed?
I would look at the PFJ a little more closely. This could easily refer pain to the medial knee. compression of the PFJ at different angles, Mcconnell’s test ( http://special-tests.com/knee-tests/mcconnells-test/ ). Likely an MCL sprain but who knows, maybe she has both things going on, and pain could cause the quad weakness which can lead to PFJ pain as a result of her MCL sprain.
2)Any other treatment you would provide?
Love your choices for NM control and lumbar treatment. Good re-assess with the lumbar techniques. Any re-assess after NM control drills (I know this can be hard to re-assess, and may take many visits before you see expected changes, just asking!)
I understand the idea for the anterior tibial glides; how were they working for her? did her extension improve? I’ve seen patient’s like this before who don’t improve extension after that specific technique due to hamstring spasm/guarding
In order to get those last few degrees of knee extension, depending on irritability, I like using the screw home mechanism mobilization. in supine, passively internally rotate the femur and stabilize with that hand, then use your other hand to externally rotate the tibia as you push down into extension. This might be a terrible choice for your patient, but if her pain levels and irritability improve, you can try it.
3)Does anyone have specific parameters they use for return to run/walk program?
Ability to walk without pain for 10-20 minutes, good NM control of hip/knee/ankle
Return to run program (from OCS current concepts) and soreness rules (from University of Delaware) is attached:
When they say soreness, it’s not muscle soreness, but their **pain –> https://www.thompsonhealth.com/Portals/0/_RehabilitationServices/PT%20Mgmt%20of%20Knee/Soreness_Rule1.pdf
4)I have not used manipulation with this patient as of writing this. Articles describing the use of manipulation for pnts with knee conditions usually describe the benefits stemming from increased quad and gluteal activation reducing PFPS or improving pnts muscle activation following ACLR. How do you think this case varies from those presentations and how would you have you added lumbar intervention to treatments if at all?
https://www.ncbi.nlm.nih.gov/pubmed/25540713 – Our boy Dhinu’s article on the subject.
I think this case differs in that the patient has had a longstanding history of LBP, and meniscal pathology is obviously much different from PFPS. Either way if you have decreased quadriceps activation it can lead to changes in gait mechanics which further stress the pathological tissue. I think that pain desensitization benefits can be had as well.
Anecdotally, I have a 55 year old female patient with a jacked knee (3-4 surgeries, followed by PRP and stem cell treatments in September, significantly worse after the injections), and she had significantly decreased knee pain and pain free ROM with heel slides post lumbar treatment including manipulation. N=1, but that’s what i’ve got in my experience.
1. Agree with what others have said. I think another reason the researchers may have wanted to exclude this group is due to ceiling effects. We may not expect a 65+ year old to have as much functional improvement as a 45 year old, and disability measures used here are sometimes correllated to working status, and this group is much more likely to not be working, either due to retirement or health reasons.
2. I love the FABQ, obviously, but it isn’t perfect. Often I will have a patient that subjectively seems very low fear, and then their FABQ is very high, or vice versa, and this can be hard to discern their true level of fear. I like the pain self efficacy scale that August mentioned as well. I have attached an article from European journal of pain that goes through close to 20 years of research on this measure.
3. Graded activity for sure. Ease into it! I ask about what they feel they can tolerate .. i.e. how many minutes do you feel you could walk without an increase in your symptoms. Take the number they give you and divide by 2, and start there.
4. I ask this in every evaluation, rather early, in my social history. Occupation, marital status, children, their ages, activity level. I am going to talk differently about exercise to a 40 year old female who exercises 5x a week with friends in different exercise classes vs a 40 year old female who has never exercised. This also can change my subjective questioning (does it hurt during classes? have you ceased classes because of this?)
5. I usually go the cheerleader route. I can point them to exercise-only self pay sessions at our clinic, the YMCA right next to our clinic, or a physician referred exercise program at the ACAC (gym) near us. I will often recommend they join their local gym and then have 1-2 f/u visits at our clinic to discuss how the transition is going, trouble with certain exercise machines, etc.
FYI, YMCAs usually have some sort of “medical liason” who you can speak with to discuss your patient (after signed HIPAA disclosure form), their history, what machines may be beneficial. We recently did this with a few patients, and it really helped smooth the transition.
Great articles.
One thing that stuck out to me was that the contact forces between the tibia and femur were no different in patients who had a complete meniscectomy vs a posterior root tear. This shows how important those hoop stresses really are!
The second article has a lot of studies of previous outcomes for root repair, which seem promising. However, it was interesting that one article found that in patients who were found to have a posterior root tear that was previously undiagnosed during ACL reconstruction, if the root tear was left untouched during surgery, there was no difference in arthritic changes 10 years post surgery vs controls. No mention in that study of the quality of the tissue at the root tear, complete vs incomplete tear, loss of hoop stress vs no loss, etc
In Nic’s case, I believe this patient was a bit older… I can’t really remember. If I was, say 55-60 years old and I had a posterior root tear, I think I would rather have a TKA vs having the root repair with that crazy recovery period. If I was really young… I would consider the repair.
We recently had a 70 year old male in the clinic with a posterior root repair, and he is not doing well with the recovery at this time. He’s having a hard time getting ROM back, lots of pain even 3 months post…