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Kristin, I think I may just need more practice feeling those movements in general, as single leg with a patient with more soft tissue in that area results in me having a fairly poor sense of the quality and quantity of the movement. Your point is a good one though: making modifications can be very helpful, but you do not absolutely need to perform every technique on every patient.
Would it be possible in the next course weekend for you to show us some of the modifications you find most helpful with larger patients? Like you said in the end it comes down to biomechanical advantage, but I think some additional examples from someone who has had experience with modifying techniques would be helpful to get us thinking more about this topic.
Justin I think that this question parallels our discussion regarding protocols in the other thread. Essentially these guidelines may generally be helpful in decreasing non-helpful or potentially negative treatments but the idea that traction absolutely, 100% of the time shoulder never be done obviously ignores the possible impact of patient belief. Similar to the protocols post-operatively, these are guidelines and each individual patient case may call for greater variation, just as Nick mentioned he has occasionally done.
Your question made me think of something though, Justin. This is a private group but one that is funded through and heavily connected to the English government, thus I would assume they have a fairly wide reach. One of their goals is to “Enable people to be accountable for their care, knowing how they will be cared for in a consistent evidence-based way, thus building patients’ confidence in NHS and social care services.” Do you think this information is reaching patients? Do you think that these guidelines are potentially changing people’s perceptions of common procedures in the low back? We talked today about the change in low back surgery in the eighties and skyrocketing costs associated, would guidelines like this from the NIH in the United States make on impact on patient beliefs and thus decrease cost?
Kyle, I would say that what your sentiment on second guessing treatment decisions is mostly what I drew from this article as well. Just the week before I had a prolonged conversation with Michael regarding a patient during mentoring time who we had seen at eval with what appeared initially to be reactive adhesive capsulitis following a flu shot. Michael and I were discussing my treatment plan and progression of activity, which eventually led to the topic of this article. My biggest fear was that I was being too aggressive and was continually re-aggravating her shoulder. I think your comments and this article really highlight the importance of reflective practice and constant re-evaluation.
Also if anyone has extra time on their hands/wants a good laugh then you should read the comments on the article, some very interesting opinions in there as well!
I don’t think this changes anything as far as my practice, but I like the relatively simple language that they use for their intervention recommendations, as this is intended for use by clinicians as well as patients. Unfortunately that comes with the issue you brought up Nick, that their recommendations are strongly worded. They discuss this more in the “Making decisions using NICE guidelines’ link were they say “Some recommendations are made with more certainty than others. We word our recommendations to reflect this.” Their language seems to be at odds with their stated goal of improving communication and care between patient and provider, as such a strongly worded recommendation may not be in agreement with a patient’s belief that an intervention like traction would be beneficial for their back.
Aaron, I stand corrected on the slump for neck pain I guess! I’ll be on the look out for it more when it comes to HA literature.
As for why cervical classification may lag behind lumbar, my first instinct has to do with the money related to each issue. Injury and pain in the lumbar spine leads to a great deal of lost productivity and chronic use of money and resources. At least attempting to match interventions as previous classifications have done, or highlight interventions which are not well supported, or identify those people who may develop chronic cases all potentially improve patient outcomes and thus decrease the use of resources. I would imagine that the studies that are most likely produce results that lead to an increase in productivity and thus decrease in spending get the most support and funding in governmental grants. I don’t have good comparison values for the lumbar and cervical spine, but my guess would be that low back pain is more costly in terms of care/imaging/productivity.
I think that this article describes non specific chronic neck pain well enough with the central dysfunction category. This section hits the biggest things that stick out to me, with allodynia, maladaptive behaviors or thoughts, pain persisting past tissue healing, and a widespread, seemingly non-anatomic distribution of pain.
Hi Kristin, thanks for the unique article. I would say that in the past I definitely have been guilty of choosing other options instead of a particular manual technique in deference to the patient’s size. Obviously this might be a disservice to a large portion of the population and a very large portion of the orthopedic patient population depending on your clinic’s demographics. As someone with low back pain that has affected my ability to practice already I think this article was helpful in highlighting the need for creativity to work around practitioner or patient barriers.
I’ve not had this issue but I would love to hear how anyone has modified the long axis hip distraction manipulation to a patient that is larger.
One issue I have noticed with assessment and also applies to treatment, but what have people done for lumbar PPIVMs for larger patients? Are you utilizing more rotation and lateral flexion to get facet opening/closing versus straight plane flexion and extension?
Hey Scott,
Thanks for posting the article. While a bit busy, I think that this article definitely does a nice job summarizing some relevant subjective and objective features of different neck pain types, which like you said, can be helpful to have as a student/new grad. A few things stuck out to me:– Maybe someone with more familiarity with Delphi studies can explain this to me, but isn’t Round 3 of this process pretty prone to group think biases? Like if I didn’t highly rate a particular aspect in Round 1 but everyone else did, aren’t I more likely to fall in line with other people when the voting occurs again in Round 3?
– What do you guys think of only 21 experts being involved in the final voting?
– Curious what everyone’s thoughts were on this quote from the discussion: “Regarding the ‘input’-related dysfunctions, the authors are aware that an anatomical-based classification of symptoms seems undesirable. Nevertheless, despite the assumptionthat pathoanatomical factors are of low importance in clinical decision making (Weiner, 2008), their relevance cannot be erroneously disregarded (Ford and Hahne, 2013). It is clinically important to distinguish between different tissues (Woolf et al., 1998)”
– Finally, it’s mentioned in the discussion, but how many of you guys are using the slump for neck pain???One more question Nic: had the patient tried a counterforce brace for the elbow yet? The reason I ask is that one of our CHT was just talking to me about a patient she was seeing who had LE and was prescribed a brace by her doctor. The brace was worn too tightly and the patient actually did end up getting radial nerve entrapment distally. The CHT was saying that apparently this is not too uncommon. Just something for everyone to keep in mind if your patient comes in with one of these already on their arm.
1. I think like Erik said, it makes some sense that if there is an association between ipsilateral shoulder motion and ipsilateral EO then there likely would be contralateral IO activation as well in order to reinforce that particular postural correction.
2. Honestly I have vary little confidence in being able to accurately palpate TA versus IO, especially in any patient that has a BMI over 25 (a large number of patients). Typically what I am looking for is 1. can the person contract without firing their RA and 2. can they hold a contraction with diaphragmatic relaxation.
3. I use several different SA exercises in the clinic, including the push up plus, sidelying flexion, scapular DB punch. I think that the isometric exercises presented here might be great options for irritable shoulders that still need scapular strengthening. I have one gentleman in his 50’s right now who has a labral tear and multiple comorbidities, and this is the second time he is trying conservative management because his ortho is hesitant to operate on him currently. He doesn’t tolerate a lot of therex but obviously needs to improve these force couples. I think both of these isometric exercises would be great options for him.
4. I tried to quickly search for this issue specifically and couldn’t find anything, but would be interested in what others might have found.
5. I think that this just highlights the importance of performing more complex and compound movements for shoulder rehab if appropriate for the patient. I bet that doing a squat into a shoulder extension probably reproduces increased abdominal contraction and facilitation of scapular stabilizer contraction as well. I like the idea of performing more isolated movements earlier in the rehab process, but I think that cueing for abdominal contraction during more complex movements really should be our focus.
Nic, thanks for posting the case. It’s nice to talk about a wrist/hand case.
What other screening tools/tests would you use for this pt presentation?
Scott and Justin already hit on the neurodynamic testing and further cervical testing, but I just wanted to highlight the need to (eventually) perform PAIVM assessment of the C spine. As Aaron talked about last weekend, what might seem like a slam dunk peripheral pathology may actually have a spinal component that simply isn’t revealed by normal cervical screening.What other objective measures would you test/did I leave out?
I think I would have liked to see you include a functional reassessment sign within your exam. Having the grip strength is great, but try to reproduce the every day movements that bring on at least her wrist pain would be good to track your progress and get patient buy in.What Tx strategies have you used for lateral epicondylalgia or TFCC dysfunction?
I have only ever informally treated a family member for LE, but they did well with a lateral glide self mobilization. If you find good treatment effects in clinic with your MWM lateral glides then it likely would be a good option for home. Like Scott said and like what some research says, if this is already a chronic condition then the progress might be slow anyways, and finding good self management strategies may be the focus of your treatment for the elbow.How do you manage chronic pain and overuse type injuries in patients who do not have the option to take rest/time off work duties?
It might be hard to recreate some of her work duties in the clinic, but like Justin mentioned it might be beneficial to analyze and modify her body mechanics with particular motions or positions (like on her motorcycle).Have you utilized taping techniques for these or other body regions?
I have not used taping for either of these conditions. I was actually just taught a similar taping technique for the infrapatellar fat pad that I plan on using in the coming week.Should shoulder strength/conditioning be included in progression of tx program?
I think if she has deficits in these areas then you definitely should address them. She has a physically demanding job and a hobby in horseback riding that requires a lot of strength in the shoulder. Even just managing the tack and cleaning the horse requires significant stability and endurance in the entire scapular girdle and UE, and if she has deficits proximally then she may be compensating with excessive elbow and wrist motion/contraction.Justin, I think I like the standardized process and scoring that the FMS and SFMA provide, as it would help as quick frame of reference for how the person is changing from check up to check up. I think if this model is where our profession goes then we will get more and more whole body screening metrics that are produced by private companies and by research groups. Is anyone familiar with any other standardized tests similar to the FMS? Scott I know you perform comprehensive screening somewhat regularly in your clinic, what sort of standardized method are you typically using?
My only concern with using something like the FMS/SFMA in our checkups would be that it might be easy to fall back on such an assessment as the primary driver of exercise prescription versus using our clinical reasoning. I think I am wary of anything that looks to assign a certain set of exercises to a particular measured deficiency. To be honest I am not very familiar with either screening tool so someone else chime in to correct me. I realize it is meant to be a screening tool but would not want its regular use to take a large role in our evaluation and treatment of patients.
Myra, I think the best example of a patient receiving a negative influence from an HEP that remains static comes from our discussion this weekend for the lumbar spine and abdominal bracing. I do think that more non-functional stabilization exercises can play a role in our rehab of low back pain, but can understand how too much of that type of exercise or too much of that type of education could have a deleterious effect on a patient’s pain, function, and overall perception of movement. I’m sure plenty of patients are discharged with an over abundance of core stabilization exercises and end up over activating and not actually relaxing regularly. I also could see situations where a set of exercises are appropriate for one condition, say in the shoulder, but with increasing age and continued activity, the pathology shifts on a continuum of injury and those original exercises are now over loading structures.
Similar to what you said Erik, I think that overall PTs being a provider you see 1-2x/year would have a good overall effect, but I’m not sure if it would truly lead to more person centered decision making. You mention dentists as an example of this model, but I don’t think seeing my PCP or my dentist regularly has actually added any great personal understanding that influences my care. Maybe this would be different for PTs or maybe this model just takes longer to yield results, but I’m not so sure that when yearly we see one patient out of a hundred plus other patients that our care would improve considerably.
Overall this article was helpful for me, but not for the reason you stated Erik. I actually think we as PTs manage the person centered decision making model fairly well. Personally there is room for me to improve on more frequently reassessing patients’ thoughts and feelings on their goals throughout the plan of care, but I also think this is something most of us are doing on a regular basis, albeit less explicitly. At the beginning of most sessions I typically ask about the patient’s pain (depending on how much the patient perseverates on their pain) and the status of some of their functional goals. For something that occurs every day for the person I think it is fairly easy for me to ask them about how walking/stairs/sleeping have been.
What struck me more about this article was the point made about family and decision making. They mention that some clinicians are actively suspicious of family being present, and I think after a few bad experiences early on, this description fits me fairly well. Just this past week I evaluated a gentleman with his wife present and I noticed that I immediately was off-put by her presence and initially tried harder to not engage her as much in the subjective exam. She ended up being an important resource for information and definitely contributed in a meaningful way to the goal setting discussion. I think that experience and this article really drive home the point to me of the importance of utilizing family as a resource, not as a dreaded barrier to patient communication.