Forum Replies Created
-
Posts
-
I agree with your sentiment, August. I think this study is most useful when imaging and clinical presentation do not match. Also, it might be useful for patients who start bringing up surgery even with relatively normal findings on MRI. Showing them this study might put them at ease a bit that their findings 1. may not be truly significant and 2. may not be the source of their pain.
This is a great addition to my current “Imaging Sucks” folder on my google drive.
Cool Case. Any updates yet?
After reviewing the article and based on your patient’s lack of reproducing signs except for 1, I would love to see some femoral nerve testing or mobilization, and maybe get creative with different ways you could tension/glide the ilioinguinal/genitofemoral nerves, and see if that re-assessment sign improves.
Very interesting article that makes me rethink the scapula. It really just reminds me of the growing body of evidence about “posture” and how it’s not as big of a player in dysfunction as previously thought. For example, the article I linked below shows little to no correlation between thoracic spine posture and shoulder pain.
I like the author’s advice to consider a that the scapular muscle work more as a global synergy, therefore strengthening individual muscles may not have the intended effect. The author then suggests giving the scapula more movement options by lengthening tight muscles and the T-spine, and then doing more global retraining on load transfer of the scapular muscles, regardless of scapular position.
Cool article. In regards to the clinical reasoning, obviously there is a ton of mention in there for imaging, which we don’t rely on as much. Its very interesting that their way of thinking is so based on “What can surgically correct on this person”.
As Justin mentioned, you don’t see much mention of facet joint dysfunction. It may be that this isn’t a common area to do a surgery, whereas we see it quite a bit as the source of dysfunction.
The most interesting thing to me were the stats on THA and low back pain. I think the articles that they cite are a great marketing opportunity to physicians. Read this nugget:
“In a retrospective study of 3,206 patients with hip OA (566 of whom also had LBP) who underwent THA, Prather et al reported that, although all of the
patients had improved pain and hip scores, the patients without LBP had greater improvement in function and pain relief, incurred fewer medical charges per episode of care, and spent fewer days in the hospital per episode of care compared with the patients who had LBP”I would take this article to any hip specialist and say that they should send their prospective hip surgery patients to me to treat their LBP because it will improve their surgical outcomes.
Here are a few other hot takes from this article that I think are interesting:
“The inability of a patient to lie on his or her side is likely caused by trochanteric bursitis rather than lumbar radiculopathy or intra-articular hip pathology.” – I’m don’t always think this is the case, as the mild lumbar sidebend in this position can also exacerbate lumbar symptoms.
“If a limb-length discrepancy exists, blocks should be placed under the patient’s short leg to obliterate pelvic obliquity before observing spinal alignment.” – This is interesting because I think I would like to see their normal alignment and how they move throughout their day first, and then see what happens with a heel lift second. Many times the person had no pain for years despite the leg length discrepancy.
“Trendelenburg test also may be positive in patients with L5 radiculopathy
as a result of the innervation of the gluteus medius and minimus.” – I don’t consider this much in my clinical reasoning. Clinical pearl noted! Check L5 with all trandelenburgers.The best sentence in the whole article – “Care should be taken to correlate a patient’s diagnostic tests with his or her history and physical examination because positive findings increase with patient age.”
“Leriche syndrome, which is a form of internal iliac artery stenosis, can result in buttock and thigh pain.” – A great thing to add to our differential as a vascular source of pain!!! I expect this on all clinical reasoning forms for buttock and thigh pain.
I know this is a novel.
I had a cervical radiculopathy patient that I flared with a combination of aggressive mobilization and providing a nerve glide as an HEP. The guy was pissed, but it also really worried him. He thought he was getting worse. He was thinking about retiring in a few years and wants to sail around the Caribbean, and he was starting to think that this neck pain might be affecting him and he’ll need surgery.
Patient was improving so I thought it was okay, but obviously not. If the person has high fear, or anxiety, I would not usually prescribe something unless I had seen their response next visit.
You never want the patient to lose their confidence in you.
1. I have only seen one patient with questionable TOS symptoms. It was during my first 12 week ortho clinical. She had shoulder instability, and then 2-3 sessions in, developed burning and tingling in the forearm and hand, worse with scapular protraction. We ended up doing a 1st rib manipulation, which relieved all her tingling and burning. It didn’t help her shoulder instability, and it was my first clinical, so take that for what it’s worth.
2. As Erik said, usually not first day due to possibility of flare, however I like that you prescribed a very conservative one the first day, and it involves a very small amount of scalene motion which could also be beneficial. Good choice!
3. I think the Eagles will win the Superbowl in 2018.
4. This is the pot calling the kettle black, but I think the obvious answer is to treat one thing for a good amount of time (5-10 minutes on scalenes) and then reassess. Better? great, those are likely involved. Next 5-10 minutes on pec minor, re-assess, etc on down the line of possible contributing factors. Anything that made improvement stays on your list of daily treatments/HEP/subsequent visit reassessments.
I say this, knowing that full well it is incredibly difficult to stay on task with something like this. I don’t have any special tips to stay on track, other than to stay with your clinical reasoning, and fight every instinct to just give the person scapular retractions, rows, and extensions out of inertia.
5. Tough question. Never an easy conversation. If it is truly exacerbating their symptoms, then a psych referral is warranted. I think that if you can demonstrate to the patient that their emotional stressors or psychosocial factors make their condition worse, they will buy in and maybe follow through with seeking psychiatric care. If this thing really isn’t getting better, and the person doesn’t want surgery to attempt to fix it, then a referral to a social worker or case manager would be warranted to discuss disability. That might really scare them or prompt them to agree with your recommendation to seek psych care. Sending back to referring MD is a must to discuss other treatment options and let the patient decide if those more aggressive treatment options are worth the risk, or if psych + PT can allow full return to work.
Honestly, I haven’t had to have that conversation with someone, but I know it will happen in my career at some point.
I usually start with Adrian Louw’s alarm analogy. For patient’s that need more, I will give the example of the construction worker with the nail through his boot wailing in pain, but come to find out the nail went in between his toes. I think that example can really illustrate how pain is an OUTPUT of the system, and not a specific input.
This usually opens the door to talking about how many complex things can modulate that output like sleep, depression, fear, etc.
I think that’s a great place to start with people, and then it has to get more individualized.
I have a difficult patient right now that has chronic LBP s/p surgery ~1 year ago. He is really having trouble understanding why he is still hurting after the surgery. His daughter got married in September and he danced with her at the wedding basically pain free, and his pain started up again the next day. That was a powerful example to him showing how your surroundings and mental state can affect pain.