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This CPG is super helpful in identifying different systems to assess and address post-concussion. Examination can be guided by questions and objective measures from each of these areas to determine the degree of involvement of each.
For the motor function component questions about balance, dual tasks, gait difficulty, coordination will help clue into impairments. Depending on the severity, you could expect that the patient report noticing balance and coordination difficulties during ADLs, gait, or other activities they may have tried. Based on the severity, PLOF, age some sort of standardized balance measure would be helpful to track progress (BBS, Tineti, DGI, HiMAT, walk while talk, etc.), but if these assessments aren’t rigorous enough being creative and using various functional assessments that you standardize to track progress as. Then functional assessment in general would be more geared towards challenging static, dynamic, double and single leg balance.
Treatment progression would likely start pretty basic (again depending on current level of function) with maybe just some static balance stuff then progress to dynamic and with dual task as able and ultimately mimicking activity/sport requirements.
Agreed with Steven that the gist of this visit should be red flag screening and also doing a neuro exam. It is definitely concerning that she is experiencing these new symptoms. Cauda equina and pelvic organ prolapse are my biggest concerns.
I would for sure call her PCP and let them know the urgency of the situation, and discuss with them the need for her to be seen by a specialist or go to the emergency room if unable to get in with them within a reasonable time. If I had the connections, then calling the specialist directly is another route, which seems like what you did Kyle.
I thought the course was very helpful to give more of a framework for identifying and treating neurodynamic components.
There have been a few patients that I feel I have gotten more clarity and have benefited from varied treatment because of what I learned. I either didn’t really consider neurodynamics as a component or just wasn’t sure the best way to incorporate this into their treatment.
One patient in particular is a lady with weird shoulder pain that just wasn’t really adding up to match a recognizable pattern, but with some more specific neurodynamic testing I got more clarity on what was contributing. It seemed neural to me but I just wasn’t specific enough on initial evaluation- I only did ULTT 1 and didn’t get much and could have done a better job with cervical assessment. But on the first follow up visit I assessed the other ULTT and radial was positive and then was able to follow that up with palpation and cervical PPIVM and PAIVM to continue to gather information. This then helped me to be more specific with my treatment and I have a better idea of how I want to progress her.
Subjective questions- history of previous orthopedic injuries and fractures, activity level and nutrition, PMH (specifically looking for anything that may alter BMD), what able to use arm for if anything, swelling after injury, specifics about the fall
Objective- palpation, ROM, tuning fork, ligamentous testing to determine irritability and (+) findings to guide treat or refer
Because of age have to consider patients ability to communicate and level of understanding, coping mechanisms for pain, motivating factors (to use or not use arm), emotional status
I actually had just read this and sent it to my student yesterday to discuss as well! We have had this discussion many, many times throughout her clinical and I have shared a lot of evidence to challenge her fears and beliefs with the “big bad wolf” of OKC after ACL-R.
I definitely used to have the mindset of staying way clear of OKC b/c had that perception based on what we learned in school and also one of my CI’s was super adamant that no one, and especially post-op ACL patients, should be doing open chain knee extensions. So based on this I leaned towards the “house built of straw” side of things vs “house built of sticks” earlier on in my long 1 year career.
But after listening to various podcasts and reading different articles over the past year I definitely have started to implement OKC post-op as I feel like this is a great isolation exercise for the quads that is safe when progressed appropriately. So, this article itself doesn’t really change anything at this point because I have already changed my practice pattern but it does add support to the ways I have changed treatment.
I particularly like how this blog post talks about implementing OKC exercises and presents a lot of evidence behind her statements- https://www.nicolesurdykaphysio.com/2020/05/10/the-case-for-open-kinetic-chain-exercises-in-aclr-rehab/
Definitely a good read. This will be useful going forward on many fronts-identification of modifiable and non-modifiable risk factors to guide exercise progression based on healing, education on modifiable risk factors and emphasizing importance of lifestyle changes, discussion when referring with suspicion of non-union.
Steve- I, too, have tried to be better about adding more reflective questions during my initial evaluation and subsequent treatments. They just give so much more helpful information a lot of time. I feel like I don’t often directly ask if people are scared of movements, but, in some situations, can see how this would be helpful then follow up with a question on why they believe that.
Barrett- I like that last question and don’t know that I have ever asked it in that way but can definitely see how that is helpful to get them to reflect and also open up a door for us to start the discussion.
I also think that just asking what the patient what they think is going on or what all of the medical “diagnoses” they have been told mean to them is useful as well.
Man where to even start…
I feel like overall I am just so much more efficient of a thinker. As a result (to name a few) I can better fine tune manual and exercise prescription within session, get clarity in the face of uncertainty, redirect when things aren’t progressing, and, maybe even more importantly, have brain power left over to build better relationships with my patients. To be honest being more confident and efficient in patient care just makes the job more fun.
I can agree that “soft” skills have been surprisingly difficult to be effective with. No patient is getting better without good education and framework for treatment, and this is something I have learned the hard way in the beginning but improved with thanks to both practice and mentorship.
In the same boat as the folks above. I think it is huge to make sure you have good patient rapport, but what this looks like may be different based on age I feel like. I like how the one article gives a nice little flow chart and think that to some degree “checking” the boxes associated with PT factors can help us to reflect a little bit on how we are relating to the patient and guiding their care to see if this may be a contributing factor to the changes in affect.
I would hope that after seeing this patient for 3 months now you have the relationship where you can ask her questions about how things are going with school, how she feels her progress is going, etc. I think general questions to start may lead into some opportunities to get more specific. Ultimately we can’t be motivated for her if she doesn’t want to be. This will definitely have an effect on outcomes, so with noticing such drastic differences, it would be helpful to prod a little bit.
Like Steven, my approach would probably be more direct with a 24 year old compared to a likely more sensitive 12 year old. I feel like you can build a more mature relationship with this patient and if you have done your job to have good patient rapport then likely can ask forward questions and dive right into the changes. Although this still will depend somewhat on the patient’s personality and affect.
Looks like cucumber and cabbage are out. Maybe there is a correlation between foods that start with the same first letter as COVID and COVID mortality?
Design definitely influences my thoughts on the credibility of the findings and my clinical reasoning within the limitations of the article.
I do think that correlational studies have value but have to be careful not to in your mind make it a causation. An example that comes to mind for me is some of the studies on ACL-R return to sport that correlate decreased re-injury rate with waiting until 9 months for return to sport. This isn’t saying that returning before this is the cause of injury or giving a black and white cutoff, but still gives good information to guide return to sport based on data from large ACL databases.
I think that nailing down cause and effect in PT studies is hard to do, so I feel like there are a lot of correlational studies that can still add value to helping with decision making.
What is your differential diagnosis at this point? pubic ramus stress fracture or avulsion fracture, adductor tendinopathy or strain, pelvic floor dysfunction
Would you refer, treat and refer, or treat only? With high suspicion of a fracture and no improvements with treatment seems like a refer to me. To help make this decision though a few things I would want to know- what her training looks like (has she stopped, continued, modified?), what specific manual therapy and exercise have been prescribed and why, history of orthopedic injury (especially other stress fractures), and progression of pain (worsening, getting a little better, no improvement at all?).
How would you continue this patient if you keep treating? Discussion about training load and nutrition is definitely warranted and further referral to other professionals as needed. For this runner I think that hip and core strengthening/NMR would be a good place to start.
Definitely an interesting case and good resources to read through and guide decision making and management!
Kyle I am assuming this was one of your patients- What did your education and return to running “protocol” look like? Were there other psychosocial factors that you picked up on associated with history of anorexia and if so how did you manage this?
1) You could try doing two different searches (manual and CCH and manual and cervicogenic dizziness) to get more results between the two compared to having both in the same search. But if you felt like you got adequate results with that strategy then I think what you did is fine.
2) Before reading- In terms of research my understanding is that there is evidence for their efficacy for patients with cervicogenic headache and I prescribe them in this population, but also think they can be beneficial to facilitate rotation range of motion in other patients as well.
After reading- still seems like an effective treatment for symptom improvement in those with CGH.
3) The large impact that just 5 self-SNAGs had compared to the placebo is interesting- I am looking forward to discussing with others their thoughts on some of the methods.
1) I have not had anyone with this so far, so don’t have any helpful information to give based on experience.
Kyle- Thanks for sharing. I haven’t specifically used that strategy or something similar, but good to have in the back of my mind if a situation warrants this type of intervention. I do often use deep breathing with these patients though when doing exercise and have mixed results, but often see a good response in terms of tolerability to exercise and movement.
I would want to perform a neuro screen, lumbar ROM, and assess strength of proximal musculature of both UE and LE to help determine if this is a isolated LE problem associated with stenosis or can be attributed to the change in medication. It would also be helpful to ask more about when he has been experiencing the cramping, any recent changes in activity or diet, and water intake.
I would refer him back to his PCP and discuss the recent changes in presentation since the changes in medication that warrant further assessment by the PCP.
I am definitely a culprit of looking over PMH and medications in the patients chart prior to evals but then not thinking much about it during the eval. I think that it should become more of a standard of practice of mine that when reviewing medical history with patient I ask about medication use and changes to help remind myself of potential interactions.
1- With this stating there is no significant benefit or harm from e-stim and facial exercises it does leave me with the question of where to go from here and what I should use to guide my treatment of something I don’t have any experience to draw from. Those interventions would likely be my first thought just from learning from other clinician’s experience. This is kind of further answered in question 3 but in the absence of evidence to guide me using reasoning to draw from other similar treatment concepts may be where I go with this patient. Education is a low hanging fruit though and could go a long way in helping this patient better understand progression, treatment options, and expectations. I would be curious to see the incidence of those with Bell’s palsy that end up going to PT and specific patient or disease process characteristics that may be a common denominator.
2- I think it can be difficult to use a systematic review to completely guide treatment decision making in a more obscure pathology like this that may have such varied presentations, severity, and timeframe of resolution/improvement. Looking more in depth at some of the stronger studies and being able to analyze and reason through the studies specifics might better help guide treatment. With the systematic review I have a lot of questions about the different studies, such as- specifics of the interventions, characteristics of the patients, duration and severity of the pathology (to name a few).
3- With this being an inflammatory LMN lesion part of the treatment, as the introduction of this article pointed out, is time for the inflammatory process to decrease as well as nerve regrowth to occur. I think some treatment principles that can help guide are facilitating motor unit activation and reversing muscle atrophy and weakness. So a few concepts that go along with that are isolated/specific muscle and/or movement exercises and NMES, which are unfortunately the things that this SR shows poor evidence for.