April 2019 Journal Club Case

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    • #7483
      Erik Kreil
      Participant

      Hey guys,

      Please see the following attachments and answer the questions at the end of the case. Looking forward to a great active discussion this month!

      • This topic was modified 3 years, 1 month ago by Erik Kreil.
    • #7494
      Erik Kreil
      Participant

      Attached is the case PDF.

    • #7496
      Matt Fung
      Participant

      List your differential diagnosis after the subjective exam.How does this re-rank after the objective exam? Primary hypothesis to conclude?
      Post subjective:
      – Lumbar clinical instability
      – Lumbar discogenic dysfunction
      – Lumbar facet mobility dysfunction
      – SIJ dysfunction
      – Myofascial hypertonicity
      Post Objective:
      – Lumbar clinical instability
      – Lumbar facet mobility dysfunction
      – Lumbar discogenic dysfunction
      – SIJ dysfunction
      Primary hypothesis
      – Lumbar clinical instability (+resting posture, movement screen, TrA control, prone instability test, PA shear testing, aggs – sitting prolonged periods of time)

      Are there any components of subjective or objective exam you would have included during the IE to help clarify your DD list?
      – I might have asked a little more about her responsibilities in relation to taking care of her mother-in-law. Does she require any assistance with transfers? ADL’s? etc. and how do these activities if she participates in them affect her symptoms?
      – Is her only goal of PT to make sure that her back pain does not get worse?
      – Also I’d like to know a little more about what finally brought her into PT if she has been dealing with these symptoms for over the past 1-2 years?

      List any Yellow or Red flags you’d consider for this case.
      Red flags – none
      Yellow flags
      – “I know my back is a mess. I’m just hoping you can help me, so it doesn’t get worse”
      – Occupation: caretaker for mother-in-law with depression -curious what her daily interaction is like and how that affects her
      – Avoiding leisure activities, i.e fishing, hiking – due to fear of pain
      – PMH of depression

    • #7497
      Cameron Holshouser
      Participant

      1. List your differential diagnosis after the subjective exam. How does this re-rank after
      the objective exam? Primary hypothesis to conclude?

      Subjective:
      Doesn’t seem to fit a specific pattern and could be a combination of pain producers. Seems to have a large biopsychosocial component due to her job as a caretaker for mother-in-law. I would want to know when that started occurring and what physical demands that entails.

      1. Lumbar Discogenic pain
      2. Lumbar Clinical Instability
      3. Myofascial pain (erector spinae)
      4. Facet arthropathy

      Objective:
      – Lumbar clinical instability at L4/5,L5/S1 with high fear avoidance and chronic pain

      2. Are there any components of subjective or objective exam you would have included
      during the IE to help clarify your DD list?

      Subjective:
      Again, I would want to know more about being a caretaker in regard to stress, time of when it started, physical demands, and if there was a correlation to her low back pain. I would want to know more about getting out of bed since that is her most difficult task – whether it is stress related, static posture, or transitional movements. I would want to test standing lumbar quadrants with overpressure, and potentially linking them to a specific direction (scooping cat food, lifting laundry). What did you feel about her irritability and emotional state? How did you make the decision to continue with a more mechanical exam vs a biopsychosocial exam? How does she manage stress? She also stated she ex exercising two years ago, what did she do and why did she stop – maybe relate to her pain? I like Matt’s point of, what has changed in the past 1-2 years to make her seek PT?

      Objective:
      – Quadrants with overpressure
      – Rotation in NWB position, prone torsion
      – Hip extension activation pattern and strength
      – UPA’s
      – If correcting her squat or movement strategies (scooping cat foot) would decrease her pain
      – Single leg stance and squat
      – breathing strategy

      5.List any Yellow or Red flags you’d consider for this case.

      Red: none
      Yellow:
      – PMH: depression (being managed?)
      – High FABQ and ODI
      – Stressful job (emotionally, physically, psychologically – caretaker)
      – Avoidance of positive activities

    • #7498
      jeffpeckins
      Participant

      D/D after Subjective (in order):
      – Chronic non-specific LBP
      – Lumbar facet
      – Lumbar discogenic
      – Lumbar myofascial

      D/D after Objective (in order):
      PRIMARY HYPOTHESIS: Lumbar facet pain with movement coordination impairment and fear avoidant behavior
      – Chronic non-specific LBP
      – Lumbar discogenic
      – Lumbar myofascial

      Things to add to Subjective:
      – Is she not exercising due to her pain?
      – What things about being her mother-in-law’s caretaker aggravates her symptoms?
      – What are her goals for PT? Decreased pain vs zero pain?
      – Out of her aggravating factors, which thing is the worst? (Sitting vs walking, etc)

      Things to add to Objective:
      – Picking up object off floor –> strategy and pain provocation
      – Swing Test
      – H&I testing
      – If rotation is the worst, is there a difference with rotation in sitting vs standing?
      – Hip extension ROM

      Yellow Flags:
      – “My back is a mess”
      – “Help me so it doesn’t get worse”
      – Potentially ruminating about pain if she is not working, no kids, and being caregiver of mother-in-law
      – Doesn’t go hiking or fishing due to her pain
      – PMH of depression

      Red Flags: none

    • #7499
      Caseylburruss
      Participant

      Erik,
      1. List your differential diagnosis after the subjective exam. How does this re-rank after the objective exam? Primary hypothesis to conclude?

      Post-Subjective
      a. Lumbar clinical instability (chronic pain)
      b. Myofascial pain
      c. Lumbar discogenic
      d. Facet arthropathy

      I agree that the biopsychosocial component may be a big player with this patient. I think inquiring more about her pain beliefs would be important. I wonder if you inquired any more on this during subjective? If this was my patient retrospectively, I would have wanted her to elaborate on the terminology she used to describe her back pain and her goals. I would have loved to know what “my back is a mess” means to her? What would reflect not “getting worse”, is she referencing pain levels, functional mobility, activity tolerance? Is she stopping activity due to an assumption of pain like hiking and fishing? So many questions.

      Post Objective
      a. Lumbar Instability with lumbar facet arthropathy
      b. Myofascial pain

      2. Are there any components of subjective or objective exam you would have included during the IE to help clarify your DD list?

      Subjective: I alluded to some of the questions I would have asked above to gauge her pain beliefs. I also agree with everyone that finding out what her role in care-taking involves and what toll does that take on her mentally, physically and emotionally? Has this role changed in any way or are there any new stressors in her life? What were prior episodes of low back pain like and are there common triggers for onset? How did she manage before (get a sense of coping)?

      Sx related questions: when she is sitting can she alleviate her symptoms with movement? Inquiring about morning symptoms or with general getting out of bed motion?

      Objective: Quadrant, OP in standing (change with cues for anterior abdominal recruitment or neutral spine- interested if this changes sx with lumbar rotation as well), sitting and supine lumbar spine posture compared to standing, hip quality/quantity of motion (you said no p! reproduction, but wondering overall profile… hyper or hypo?, potentially look at lumbopelvic dissociation in quadruped

      5.List any Yellow or Red flags you’d consider for this case.
      Agree with what everyone else has said regarding this. I think knowing how she responds to pain belief questions would give me a better sense of if she is going to be a responder or not. Is she responsive to cueing and patient education to perform her chief complaints with less pain like sit to stand, squatting, postural cues, etc. How much of this is lack of knowledge of how to move or is it more deeply ingrained in her beliefs.

    • #7501
      Erik Kreil
      Participant

      I love the amount of thought we put into the DD list, and Matt you’re totally right – I didn’t even think to ask about specific requirements of care taking for her mother-in law.

      I did 3 things on day 1 (the eval): gave PPTs – hoping to just give her something central she feels she can control, talked about pacing her IADLs, and I wrote down words for myself that she used to describe her problem or pain area so I can better parallel with her during our treatments to come.

      What do you guys think?

    • #7503
      jeffpeckins
      Participant

      I think the PPT is a good first exercise. It’s not likely to increase symptoms, it will decrease the anterior pelvic tilt that is likely increasing her pain, and work on dissociating her lumbar spine from her hips in a positive way. I also like PPT because they are a good starting point to progress other hip extension exercises.

      I’m wondering if you plan on doing manual therapy with this patient, and if so, when you initiated it, what you did, and the frame of reference/set-up for it. (This may be jumping ahead to journal club).

      I like your idea of writing down her vocab list, and am also very interested to hear how this played into your treatments with her.

    • #7504
      Erik Kreil
      Participant

      Yeah, Jeff, I mean the point wasn’t even to improve her “skill” of a posterior tilt but really just to make her feel more in control and familiarized with the concept of what we’re working on.

      I’m going to give you a rundown of my follow up treatments, but a sneak peak would be that I never used manual.

    • #7505
      Jon Lester
      Participant

      1. List your differential diagnosis after the subjective exam. How does this re-rank after the objective exam? Primary hypothesis to conclude?
      I would agree with your general order and ranking due to the location, age, and subjective aggs/eases. It definitely appears to be lumbar in nature based on the subjective. The only things I might add are myofascial referral from the hip or possible SIJ referral based on the location, but I would rank these low prior to other subjective questioning.
      Post-subjective
      – lumbar clinical instability causing facet arthropathy
      – extension sensitivity secondary to facet arthropathy
      – Lumbar discogenic referral
      – SIJ dysfunction
      – lumbar paraspinal referral
      – glute max referral

      Post-objective:
      – lumbar clinical instability causing facet arthropathy
      – Lumbar discogenic referral
      – SIJ dysfunction
      – lumbar paraspinal referral

      Primary Hypothesis:
      – 100% agree with you

      2. Are there any components of subjective or objective exam you would have included
      during the IE to help clarify your DD list?
      – asking specific hip aggs/eases (e.g. cross legs, glute tenderness, etc)
      – even though this episode is insidious, any previous pain? MVA? fall? etc
      – relation of stress with her pain?
      – relation of lack of exercise to her pain? Was she a frequent exerciser prior to? Yes that’s a word I looked it up.
      – Beighton scale?

      Objective:
      – H&I, quadrants
      – does abdominal bracing reduce her pain with rotation/SB?
      – I don’t often use the BP cuff for abdominal control (I think it’s a good idea I just don’t use it) – maybe her ability to maintain the flexion endurance position? That’s just what I use more often so curious if you do as well or if it wasn’t appropriate for her case.
      – hip strength/extension ROM
      – SIJ cluster if you deemed it appropriate giving her presentation
      – Have her pick up a weight similar to her fat cat to see strategies

      3. List any Yellow or Red flags you’d consider for this case.
      – Definitely yellow flags for her fear avoidance and the comments that you listed. She seems both aware of her pain and perhaps hypervigilant to it. With all we know on this topic, we can relate the chronicity of her symptoms with this mindset. I’ll be interested to hear of any PNE that was provided for her and if it was effective. She seems like the perfect candidate for it given her presentation in paper format. I think the fact that she is a caregiver is also a yellow flag due to her reports of stress and likely needing to do activities that she perceives as painful during that process.

    • #7506
      Jon Lester
      Participant

      Erik,

      I think this is a great case. Can’t wait to hear more about how treatment went.

      When you say you used no manual, do you mean joint mobs/STM/TPR/etc? Or do you mean no hands on whatsoever including manual cueing during activities/exercises? Just curious because I could see either side of hands on being either beneficial or not for someone who presents similarly. With certain patients, I avoid excessive hands on in any form to promote active participation in their rehab and hopefully teach them that they are 100% in control of their symptoms and management. I find this helpful in those with fear avoidance and similar perceptions as it appears your pt had. I’m curious of your perspective on that.

    • #7507
      Erik Kreil
      Participant

      Yeah great point, Jon. A better statement would have been that our treatment was 100% active, so really I used hands-on to provide cuing in the beginning just so she could understand my goals for her.

      One thing I’m going to want to talk about in the live-journal club is cuing, but maybe we can toss some ideas around here before we talk as a larger group. What do you guys think about cuing for folks who may be hypervigilant or fearful of movement?

      I took this idea seriously, because I felt like it was a delicate seesaw as to at what point am I making her feel like there’s “ONLY 1 WAY to squat” for instance versus just gaining body control and awareness.

    • #7508
      Myra Pumphrey
      Moderator

      Hi all – great discussion!

      Jon – Glad to see you wanted to complete an SIJ cluster to help clear your differential list.

      All – Flexion fingertips to floor, but SLR = 100 deg, anyone want to assess lumbar PPIVMS in flexion? If so, why? How did lumbar biomechanics look in flexion?

      Curious what part of her vocab list you chose to parallel and which parts you might have chosen to help her re-think.

      Looking forward to the discussion tomorrow!

    • #7509
      Eric Magrum
      Keymaster

      Looking forward to a great discussion today

      My questions are:

      – If this case is primarily biopsychsocial (which it seems to be) – does the specific diagnosis matter?
      – How do you specifically change your exam when you realize that this is a primary bipsychosocial case?
      – How do you change your communication?
      – How do you change your treatment plan specifically?
      – What strategies have been sucessful, and unsucessful with a primarily biopsychosocial approach with similar patients?

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