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Good point Kristin. I’d say the only negative of this article was that there were too many biases too choose from (sadly), but realistically the one you mentioned should be high on my list as well.
I had one patient with lumbar stenosis early on during the residency whose outlook on their symptoms and overall personality wore on me. I realized that my dislike for his negative attitude affected my care. He ended up coming back to therapy several months later, and I think I surprised him by being more upbeat, open to his concerns, and genuinely excited to try a bunch of different interventions for his home program. His response was considerably different, and I wonder how much time I wasted by letting his personality impact my decision making earlier on.
Hey Scott or Laura, any updates with this patient?
1. I don’t often read articles with fMRI so this certainly was interesting. Any article that provides biological plausibility for what our clinical trials already are suggesting is a positive in my book. For application to clinical practice, this might be good evidence for starting a session with a longer aerobic activity in order to act as a window technique of sorts for harder functional or strength activities later.
The biggest issue with this article is the ecological validity though, as how many patients do we see that have FM/chronic pain and do not have a comorbid psychological diagnosis?
2. I think sometimes the traditional Borg RPE scale can be difficult for some patients to comprehend, but I do like the control it gives patients by telling them to raise/lower the difficulty as they see fit, just as long as they stay at a moderate effort level. I do know that some patients I have had with chronic pain get energized and motivated after a good day or a PT session and then go out and do too much activity, resulting in increased normal muscle fatigue and soreness that they might react negatively to. I think explicitly describing a “somewhat hard” difficulty might prevent this.
3. First off, I think my approach with these patients has definitely changed in the past 6 months. As we’ve talked about before, asking questions instead of always telling can make a big difference. I think I am more explicitly trying to identify where people fall in the stages of change and then providing cues/education to reach the next stage. A big part of it is just trying to find something that they will even consider doing and then riding that train. I think I’ve found the most success with setting small weekly goals.
4. When I get a referral for something like low back pain and the medical intake form also has FM marked on it for PMH, I typically try to do two seemingly opposing things 1) check the mostly negative connotations associated with that diagnosis at the door 2) realize that if my subjective and objective does rightly reinforce the initial clinical picture I have for this patient, that I will need to adjust my language/education and exercise prescription accordingly.
Unfortunately I think several of these biases are relevant to my care. One that I have started to recognize more in my practice is Premature Closure. With trying to rule out diagnoses early on in an evaluation I feel like this is less of a problem at the initial patient assessment. Where I start to run into issues is a hesitancy or blindness to reassessing during a PoC if what I am doing does not seem to be working as well as I would like. I have noticed I am much less eager to jump in and re-evaluate things than I should be because I already have a diagnosis that “makes sense”. Not as frequently, but I have found myself guilty of the Psyche Out bias. For patients with chronic and high levels of pain that also have significant psychosocial factors it sometimes is too easy to significantly ignore the actual musculoskeletal root cause of their symptoms.
Besides the above examples, I think where I have run into trouble in treating patients ineffectively due to bias has been when I have taken over responsibility for another clinician’s patient. Especially as a young clinician I look at nearly everyone as more of an authority than myself. I can think of one situation as a student where I was treating a young woman for shoulder pain, and discounted treating at her cervical spine for a significant amount of time because the initial PT doubted any cervical component. In hindsight I should have independently reassessed and potentially started on treating her neck more quickly.
1)Any other exam techniques you would have performed?
What was the quality of her VMO contraction and VMO muscle bulk palpably/visibly? You and the article talk about treating centrally in order to improve quad activation, but once you got her to full knee extension maybe there could have been value in utilizing NMES with some of your strength/balance interventions.I was curious about your clinical reasoning with the exam, why did you choose to do a slump/SLR after the lumbar spine was only minimally provocative and did not reproduce distal symptoms?
2)Any other treatment you would provide?
I think if you felt like there was a neural tension/low back component that needed addressing, performing some of the sidelying Elvey techniques might have been helping. You would be able to mobilize the back, potentially decrease neural sensitivity, and reinforce knee AROM if you have them performing knee extension slowly during your mobilization.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?
I can’t say I would have gone to the lumbar spine as quickly as you did with this patient presentation. I think if it seemed like it played a component I likely would have included therex that incorporated hip strengthening with low back control like a bent leg kickback or streamboats on airex. I think I might spend time working on the lumbar spine if when you got them on the TM for returning to run and it seemed like lumopelvic control or mobility was impacting their mechanics with running.
This has become a bigger part of my discussions with patients recently. Some patients deal with their symptoms all the time, and it can be hard for them to recognize the little differences that become more obvious to us between their PT visits. I think highlighting that difference in perception can help patients understand that our praise is genuine versus something manufactured.
The comment about ‘shared positivity’ made me think about a comment from one of the fellows at UIC. He said something corny to the effect of “often times the body has a natural ability to heal itself, we’re just here to help facilitate that in whatever way possible.” He would go out of his way to engage with even the most withdrawn patients because he thought it would have a positive effect on their care. I think for most patients this is not something that is hard for us to do, but maybe we should make a concerted effort to tell a funny story, or jokingly complain about an underachieving sports team, or whatever it might be, just to add some positivity to their day.
The other relevant aspects to patient care would be in goal setting. Going along with being able to provide patients with good information on prognosis, I think I could improve on setting up patient expectations for goal achievement as well. Sometimes patients have unrealistic goals and it can be hard to temper those expectations without sounding negative. The more I create smaller goals with patients the more frequently satisfied everyone seems to be.
As someone who can get caught up in negative self-talk, this article is interesting because I’ve never heard of the idea of “micro-moments of positivity” but have definitely noticed this sort of concept in my life. I think I need a big note taped to my desk in our office to remind my self about some of these activities, particularly resilience and accepting yourself. Sometimes it can be hard to keep these things in mind after a disappointing evaluation/treatment session/mentoring session.
1. Overall I liked this study. I thought their analysis was easy to follow, they had a long-term follow up, and had a large and heterogeneous mix of participants. As with our conversation about the BMJ OA paper, I think some of our conversation of research that is critical of our interventions devolves into ‘losing sight of the forest for the trees’. That being said a few things stood out to me for this paper. I would have liked to have seen an objective measure that may be more relevant for injury prediction, like the Y balance or SEBT. I like that they broke down their analysis to subgroups, but would have preferred if they had looked at previous ankle injury (152) versus first ankle injury (101).
2. We have literature that suggests manual therapy can be effective for ankle sprains in the acute and subacute phases of healing, so obviously my biggest gripe is the exclusion of this intervention from their treatment arm. The subjects were able to attend up to 7 sessions, and at that length of time out from a sprain I would think that some manual therapy intervention, whether it be soft tissue or joint mobilization, would be indicated. The apparent exclusion of more balance oriented interventions also surprises me.
3. Thinking about this question, I’m not sure I’ve ever seen a first time ankle sprain acutely. Everyone I have seen acutely have had multiple sprains and CAI issues such as giving out, or I see them subacutely after they have been immobilized due to more serious sprains. I think the early treatments would be similar to what was prescribed in this study, with ankle ROM, band ankle strengthening, and advice on edema management and activity modification. I think as swelling goes down and weightbearing becomes normalized I would begin focusing interventions on prevention of future sprains. The total PoC length would likely depend on how they did with return to activity. I had one patient who I saw for longer than 7 visits because she wanted to get back to rockclimbing and she was still having significant difficulty with that activity.
4. I think the easiest way to combat this would be to ask the patient what their goals are and relate my interventions into helping them achieve those goals. At the end of the article they mention that very few people had an ‘excellent’ outcome regardless of the group, and if you have any work or sport related demands at a high level then you likely want that high level outcome. I would highlight the wide range of interventions I have to offer that were not included in that research (for good reason due to the nature of RCTs) such as soft tissue massage, joint mobilization/manipulation, plyometric therex, gait retraining, specific exercise prescription, etc.
Scott, for education what sorts of materials have you provided this patient? I think it might be beneficial to show him that TED talk about CRPS that we had watched previously. The video that Eric showed during the course weekend that was from National Geographic and demonstrated the plasticity of the brain’s sensory mapping might also be beneficial to show this patient that these sorts of sx, albeit to a much different magnitude, can happen to anyone.
Justin, I think I understand the use of compression in a peds population that responds to tactile stimulation, and for this population I could see how a constant non-noxious form of input might be beneficial to decrease some of the allodynia that he is experiencing, but could you explain the rational for using a tb for compression while also performing the nerve glides?
Articles like these are always fun to discuss so thanks for posting Justin. I seem to remember an article from a few years ago (maybe from JAMA?) that had similar findings that produced some interesting discussion among some of my classmates.
1. I’m not quiet sure what to think. My understanding is that these issues would be caught early because of obvious differences in static hip positioning in the infant, in addition to continued pain and dysfunction. It almost makes me wonder if this truly was a dislocated hip or some other congenital anomaly that would require surgical intervention? Either way I think even though this is much later into the future I would have concerns about of the blood supply and bone quality around that joint, especially for a a post-menopausal woman.
2.
– Anything noteworthy about her gait, squat form?
– Since you did a slump, it might have been good to try some of the anterior hip femoral neural provocation tests that we talked through in the past course weekend.
– For someone with both lumbar and hip pain, I think it can be helpful to perform combined rotation and then differentiate which is most limited or painful. I’d assume the hip would be most limited here, but maybe if you can improve the small amount of rotation at the lumbar spine you can take pressure off the hip during functional motions.3. A few points on treatment:
– What was your thought process for the lumbar PA mobilizations? How often did you treat her low back?
– Education: What were her thoughts on conservative versus surgical management? What was your education on the natural course of OA, the role of continued conservative management, leisure time PA?
– What did her home program involve?Katie, love the article as I think that we should be promoters of PA for all of our patients in order to reduce pain and in a big picture, attempt to reduce all cause mortality and morbidity.
1. I think this article nicely provides a framework to use the TTM for addressing PA for all patients. If the previous study was set up like the current one, then the comparison was made between a normal PT care control group and a hands off experimental group in patients 65 and older. Obviously this is not really how we practice in the clinic, so I think using this framework is still a valid adjunct to our normal care, even if the data wasn’t overwhelming.
What I found curious about the exclusion criteria was the lack of screening for depression. Individuals with depression have lower PA self efficacy and levels of leisure time PA, and there very well could have been differences between the groups that would have affected the results.
The exclusion of individuals with fibromyalgia (a quarter of my LBP patients) and following work or car accidents (another quarter of my LBP patients) hurts the ecological validity of this study.
2. For fear avoidance, you could use any number of different metrics we have already discussed, possibly even the FACS (shoutout to the October article discussion thread). I’ve never heard of using a specific self efficacy metric in the clinic, as I feel like the domains of many fear avoidance questionnaires hit upon self efficacy. Looking at a recent article in the Journal of Bodywork and Movement Therapies, the Pain Self-Efficacy Questionnaire can be used.
3. Depending upon the patient’s education level, I might discuss the analgesic effects of regular physical activity. Depending on what level of activity they are currently doing, I typically try to set goals for activity within the next week for a certain number of minutes doing something active, even if it is a low MET activity.
4+5. I typically will ask during the evaluation what sort of regular activity they do, and if they don’t engage in regular PA, I ask if they have a desire to or not. I think this heavily frames my approach from there. If someone wants to be more active but is fear avoidant or has low self efficacy, I definitely try to bring it back to their goals during the evaluation. If someone has no desire to be active I typically introduce the idea that PT involves exercise. If we can even start with that I will continue to try to discuss the benefits of PA overall and for pain. In briefly mentioning the stages in the article, I like that for the contemplative phase it discusses bringing about how this change might affect others. I think this can be pretty powerful for a lot of patients in getting them to move further into the preparation stage.
What struck me about this article was for the BPAQ they highlighted the difference between the two groups, but I’m not sure if they ever mentioned what a meaningful improvement actually was? At 3 mo the experimental group only increased 0.2, does that actually matter?
Good case Scott. I’ll start with my questions and move on to yours.
– At initial eval you mention sensation changes in the objective section, is that light touch or sharp/dull, or both?
– What nerve mobilization did you give him at visit 3? Given what we learned in the most recent course weekend, would your exercise or dosage change?
– This patient does demonstrate weakness and fatigability with prolonged activity, but no longer has hard sensory changes, is not areflexive, so are you still calling this radiculopathy? Or is this lumbar stenosis with components of neural irritation/compression?1. I think if other techniques you were doing were not providing relief then I would think more about manipulation. He has the expectation that it will be beneficial, and maybe there are ways to adjust the positioning of the lumbar manipulation to make it more comfortable. All the being said, it might be interesting to see what manipulating his T spine in a neurodynamic position might due to his tolerance for running.
2. T spine AROM and PAIVM assessment. Extension quadrants with OP and compression in order to further load those structures and potentially provoke sx. Hip accessory mobility if extension was limited?
3. I think a cluster of worsening foot drop (time before occurring, slap versus complete drop), worsening patellar reflex, and worsening hard sensation changes would make me want to refer this patient to a spine specialist.
4. I think for a change it presentation like that I typically refer back to the cascade of degeneration that we have used in the course series for the cervical and lumbar spines. It could be that this patient had annular/discal lesions that once they became less acute actually felt better with loading like running, but now further down the cascade the loading into extension is too provocative.
6. This is not something that I have specifically done before. I definitely have done strength and mobility work in the thoracic spine for some of my patients with stenotic presentations, but I’ve never focused on neck posture or strengthening. I think that if we are giving education on posture elsewhere in the spine that providing more information on the C spine could be beneficial, and following that up with 1-2 simple exercises might be beneficial.
Certainly interesting reads that will inform how I will treat and refer patients with these symptoms/findings.
Some thoughts on them:
– Seems like your patient, Nic, seems to meet all the risk factors for this sort of tear (middle age, female, increased BMI, decreased sports activity)
– There seems to be several reasons why surgical management may be important for these patients. The presence of extrusion due to loss of hoop stress resistance being associated with worsening OA is mentioned several times in each article, but what I found most interesting was a possible mechanism of increased tibial external rotation and lateral glide resulting in increased varus moment at the knee and medial compartment compression. For this patient with mid-grade OA in the medial joint space this might be especially relevant.
– Given our discussion about the poor consistency of MRI findings for the low back, the fact that 33% of these tears are missed on MRI makes me want to pay more attention to this clinical presentation so that I am not contributing to potential issues diagnosing this patient in the future.
– I would be curious how many surgeons do this surgery in the surrounding area and what sorts of results they have. Given this surgeon group stressing the difficulty of correctly performing this repair because of the anatomy, I can’t imagine it is too widespread.
– The precautions listed in the second article include no CKC knee flexion greater than 70 degrees for 4 months, which very well may be appropriate given this patient’s age and the potential size of the tear, but I have a feeling like this patient in particular may have a poor outcome because I highly doubt she would be compliant with being this conservative. It sounded like she ascribed to the belief that more was better, and I think she might require frequent and detailed education on the importance of compliance if surgery is eventually carried out.Phase V
– No more than 3 high intensity/high energy storage workouts within a week, with this principle continued on for a year following the initial injury (Malliaras 2015)
Strength and power (initial transition from phase IV)
– Leg press calf raise with fast concentric and slow eccentric 3×15 (initially avoiding dorsiflexion in order to not over compress tenon insertion, as tolerance allowing transitioning into full range). Weight at or near body weight
– Leg press calf raise with fast concentric and eccentric
– SL lateral step down with heel raise on return 3×20 (focus on maintaining contact with the first ray and step)
– Sport cord high knees and push off 2 min x5 in order to introduce greater degrees of freedom and tendon loading with speed, in addition to working on running form issues
Plyometrics (prior to return to run)
– Dbl leg forward/backward hops x30 seconds
– Single leg hopping in place x30 seconds
– Single leg forward/backward hop x30 seconds
– Quadrant hop single leg x30 seconds CW/CCWReturn to run
– Running form analysis: assessing presence of possible altered ground reaction forces, potentially due increased vertical excursion, decreased knee flexion at heel strike. Assessing presence of trendelenburg gait. Because of the presence of knee varus into knee valgus with the step down task at initial evaluation, assessing the presence of this pattern with running. Assess the patient’s loading through the foot at heel strike, and whether they began in an excessively inverted position before transitioning into excess pronation throughout mid stance.
– With good response to increased difficulty of gym routine, transition into running x2 days per week and gym routine involving tendon loading x1 day per week.
– Graduated running progression attached below (Warden 2014) with at least 2 days off between running sessions. Once the patient has been painfree through the initial progression a secondary progression can be made with the patient in order to increase their mileage (10+ miles)Phase VI
– Importance of continued loading due to potential heterogeneity of tendon structure
– Continue Phase II stretching and CKC strengthening x2/wk in order to continue to resolve ROM restrictions and deficits in SL squat form. Progress with the following: SL squat on 1/2 foam roll, SL anterior/posterior/lateral foot taps on 1/2 foam roll, side step with band around feet while maintaining loading through entire foot, SL step down from greater height and on Airex/foam, contrakicks on half foam roll
– Running x1/wk 3-6 miles in order to maintain optimized load
– Running form/mechanics: utilize metronome app on phone to continue to train cadence, utilize mirrors around TM to increase feedback of running form