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Nic,
One question I had was that you put that imaging was negative, and I was curious what sort of imaging that was and on what body region?Also just wanted to clarify, when you put all hip extra-articular testing negative, does that include femoral neck stress testing and patellar percussion for stress fracture?
Given the patients low irritability, and classification in the strength/stability group, I think I would want to see some objective testing of hop distances. I know you tested them for pain provocation, but if you are having a hard time finding adequate things to reassess and measure progress, a battery of single leg hop testing might be helpful.
Well the blog post was sufficiently snarky, but the article itself was very interesting. Maybe the blog post’s cynicism is rubbing off on me, but I’m almost surprised that this would get published in Spine given its less than stellar reflection on imaging of the spine.
I think the information in this article would be most relevant to bring up with patients when their clinical examination and imgaging results are at complete odds with each other. The best way to discuss the imaging results might be to layout the basics of the article, highlighting the fact that this was done in a complete different state and only on one patient. I might say something like this: ” A study this past year by a group of doctors had a patient get 10 MRIs in 10 different locations, and they found that overall there was poor agreement on the findings and that 1/3 of the total findings were only on one report. I would likely avoid mentioning the false negative rate, as this might inspire more fear in the patient and focus on the “unknown” surrounding the low back.
I think if you wanted to be mindful of not coming off as disparaging the radiologist I would highlight the fact that some of these errors may have to do with nomenclature, schooling/different definitions, and variation in the equipment.
Scott, thanks for posting. I liked this article because it highlights the variations in the practice of clinical reasoning and mentorship. Overall our CRF and the one posted here are fairly different as far as length, organization, and content area, all due to the fact that their form is completed within a 90 minute evaluation session. I would be curious what people thought of their model versus what we do in our program. Benefits or drawbacks of each?
As far as items in our form not found in the Baylor form, the majority of them concern the more retrospective aspects of the clinical reasoning process. Our form has an entire section for a PICO question and what we learned from it. Our form also places a greater emphasis on pattern recognition in the middle and end. I like that with the recent additions there is a greater emphasis all of the potential psychosocial factors that may be present, not just one tiny box as in the Baylor form. I also like that we must explicitly put what we are going to reassess in the following sessions, unlike in the Baylor form where the greater emphasis appears to be placed on things that weren’t day one priorities.
As far as the Baylor form, I do like the concise breakdown of the SINSS into a table. As a student I had to talk through this process with my CI, and I found it very helpful for some evaluations. I think filling out a form makes the thought process even more explicit and less rushed. I also liked the prognosis section at the end of the form which asks about the natural course of the disease, as this highlights the importance of our education about a patient’s prognosis given X, Y, Z.
Maybe in an ideal world something like these forms are used in conjunction, both in the moment and retrospectively.
As several other commenters have already talked about, I like the emphasis on a thorough subjective history, and the importance of correlating imaging findings with the rest of the examination. I also liked the consideration for the interplay between hip and low back pain and pathology.
The article discusses the importance of palpation of structures and discusses some assessment of muscular strength and length, but overall I thought this area was the most lacking in the objective assessment. There was no mention of possible trigger point referrals despite discussing the muscle areas which they frequently develop. Considering trigger point injections are not an uncommon intervention to be provided in the pain management setting I wonder if surgeons as a group do not look at trigger points as an important pain producer. Glute min trigger point sure looks like L5 radiculopathy, definitely something that I would hope would be mentioned in a review like this.
Thanks for posting the article Erik. A few things stood out to me. The article talks about variability in scapular position and scapular motion and how there is redundancy in the degrees of freedom. I think this certainly is true, but my thoughts are that if multiple combinations of motions or muscle activations are less than optimal, you effectively shorten your list of total combinations. I think for someone doing a repetitive overhead motion a lack of movement variability options might lead to overloading tissues that become pathological. Restoring the total variability of motion is important, and strengthening potentially weak muscles may play a role in that.
Where I run into trouble with some shoulder patients is getting down a rabbit hole of focusing on ST strengthening and motor control when I don’t have overwhelming results when treating other deficits. I think it can be easy to get tunnel vision on these impairments and not focus on retraining functional movements. This article does a nice job summarizing the potential issues with that approach. In my mind, I try to jump to the things that make the biggest impact on pain and function, namely scapular repositioning.
Really liked this quote in reference to our discussion for the achilles last weekend: “Using various levels of resistance, speed, or both can be considered to challenge the robustness of the system to perform tasks.” The highlight on function throughout the article might be the most important thing I took away.
I like this video as a PT/healthcare provider video instead of patient education possibly. I liked the emphasis on the output of pain altering chemistry as well as muscle/joint/fascial tension as I think this is a good reminder that although the emphasis of our treatment should be on general activity and PNE, some more targeted treatments to those areas should still be pursued. I think as I dig more into this information and treating these patients I have sometimes lost sight of some our other treatments due to a hesitance to rely on passive treatments.
Justin, I like this analogy as a means of discussing peripheral sensitization and fear of pain. When you have a sunburn putting clothes near that area is painful, but people are not fearful of increasing damage in that area, and like you said, pain typically decreases after habituation to that stimulus. I like the way you phrased it, “You aren’t fearful of the pain while in the shower, why are you fearful of the pain when walking etc”. I think my metric for a good chronic pain analogy is the complexity and the number of ways it can go south. For example, for this one the patient could talk about how their sunburn continued to hurt with clothes/shower, or they could flip the analogy and compare movement of the painful area to going back out into the sun with a sunburn. I think being able to manage these moments is a very hard skill, and in my experience simpler examples are the best because they allow for less creative interpretation by that patient that may have spent 10+ years with a negative and fearful outlook.