Forum Replies Created
-
Posts
-
I like these articles because they highlight a rehabilitative approach for CMC OA. Again going with the theme of relating to other joints, we don’t always brace everyone with stability problems. Going off Erik’s point of shoulder instability, there is decent evidence to support a conservative rehab approach with non-traumatic cases. These articles highlight how conservative management with a dynamic stability program can result in significant reductions in pain and disability. I did not look, but I would be interested in an RCT of dynamic stability rehab vs splinting + rehab to see if there was a difference. I do think the hand/thumb is different than other joints because we use our hands for everything and it is a highly sensitive area (homunculus model), so maybe unloading with bracing may help better with short term pain reductions vs just rehab.
I do not have any current experience with 1st CMC OA. Reading everyone’s detailed responses have been very helpful.
Prognostic Factors
(+)
– no trauma
– gradual worsening
– absence of sensation or motor changes
– age (39)
– able to continue ADL’s
– sleep not disturbed
(-)
– stress
– job (being a mom with young kids)
– duration of symptoms > 1 year
– moderate degenerative changes at 39 y/oManagement Strategies
– Due to my lack of experience with this joint, I would try to relate to other joints that I treat frequently while keeping in mind the anatomy and function of the 1st CMC joint.– 1st thing would be to decrease load of the 1st CMC joint as often as possible for 3-6 weeks
o Education: activity modification (Assistive devices, potentially decrease school project assistance and changing meal prep for 1-2 weeks), NSAIDS
o Manual: joint distraction/glides, pain free ROM (A/PROM, AAROM)
o Splinting: I would recommend using a splint to meet the needs of the patient’s lifestyle and comfort. Based on this study, as long as the splint was client-centered, there were benefits in pain and functional outcomes after 6 weeks. Because of this, I would offer a variety of splints and let the patient choose which splint works best for them to improve adherence. If the patient did not care, I would recommend a thermoplastic short thumb splica with the MCP immobilized in 30 degrees of flexion. I think immobilizing the CMC joint would be best for someone who might have problems with stability in the CMC joint during her ADL’s.-While working on offloading the joint, I would want to focus on intrinsic/extrinsic hand muscle ROM and strength to help support the stability of the CMC complex. I like Matt’s Idea of also incorporating nerve glides with this population. I also think working on overall upper body strength focusing on functional exercises with hand modifications would be appropriate and helpful for the patient.
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 arthropathyObjective:
– Lumbar clinical instability at L4/5,L5/S1 with high fear avoidance and chronic pain2. 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 strategy5.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 activitiesDespite the article being laboratory based, I agree with Jeff that this article has clinical value. My take away from this article was that both the passive (TFCC and radioulnar ligaments) and active (extensor carpi ulnaris sub-sheath, pronator quadratus) systems work together to provide stability for normal kinematics at the wrist. If one system is impaired, the other still can provide stability at the DRUJ. If there was a true instability at the DRUJ, then you would think both systems would be impaired and may require surgical intervention.
My first line is, “So I just read your chart, but I want to hear from your perspective about what’s bringing you in here today with your (insert body region) pain”
– Some people will tell your their story (most people)
– Some people will say a one word response (“my back hurts” or “I have bone on bone”, etc)
– Some people will tell you anything and everything, not always related to their chief complaintMy response will change depending on their answer.
I try to acknowledge the patient filling their chart out because it takes people a long time (10-20 minutes). People will usually say, “Well I said that in my chart” if I don’t and lose rapport.
Eric and I have talked about asking open-ended questions at the beginning of the session, followed by more specific (but not leading) questions towards the end of the session. Sometimes I find myself asking leading questions to make the picture fit my diagnosis – this is something that I am currently working on.
The article also brings a great point of when do we answer after our open-ended question. What’s the point of an open-ended question if we interrupt immediately? This is something I struggle with as well. I have been trying to write down what they tell me initially and let them tell their story without interruption, then go back and ask specific questions about their story.
My main goal is to find out why they are coming into PT. I usually will end with something like, “lets say we get your pain better, what would you be able to do that you can’t do now (or scared to try) that you were doing before.”
Jeff, Erik, Matt – love hearing your responses on how you approach the subjective, awesome stuff.
I think everyone has done a great job describing how they would differentiate these structures.
TFCC:
– I like Matt’s comparison of the meniscus in the knee to the TFCC. However, the TFCC is much more complex than just the meniscus in the knee. The triangular fibrocartilage complex includes structures such as the triangular fibrocartilage disc, ulnocarpal meniscus, dorsal/volar radioulnar ligaments, sheath of the extensor carpi ulnaris, UCL, and ulnolunate and ulnotriquetral ligaments. The TFCC has different functions as well including stabilizing the DRUJ and the ulnar carpal bones, but also transmits load between the ulnar and carpal bones. Due to the many structures within the TFCC and different functions, saying that you have a TFCC injury is similar to saying I have subacromial impingement syndrome in the shoulder – there are too many different structures that make up this complex, and it is hard to tease out which might be the structure at fault. Because of this I would think that you would want to see if this is a compressive issue vs a stability issue or a combination of both when talking about TFCC injuries.
– There are two classifications of TFCC injury type 1 (traumatic) and type 2 (degenerative). Going back to the knee meniscus analogy, an acute meniscus tear can present very differently than a degenerative tear in the meniscus. It was interesting to note that degenerative TFCC injuries can occur as young as 30 years old based on their history. Our individual has been a competitive golfer for a long time but did have a specific traumatic compressive/rotational mechanics that caused his pain, so he could have a presentation of both traumatic and degenerative symptoms.– TFCC Tests:
o General:
– + pain with Palpation (distal ulna, TFCC – most common), also assess the other surrounding ligaments in that complex
– – atrophy / sensory changes
– + Edema
o Compression/rotation injury
– + press test (compression)
– + Compression / rotation /shearing of TFCC
– + Catching/clicking
– distraction
o Ligamentous TFCC Injury
– DRUJ motion laxity
– Carpal laxity
– Supination test
– Piano key test
– Pain with Distraction, better with compression?
– Shuck test – lunotriquetral ligament injuriesFracture:
– Intense pain with palpation over bony prominence (hamate, pisiform, triquetrum, distal radius, ulnar styloid process, lunate)
– Tuning fork
– Imaging (XR/MRI)
– EdemaECU involvement
– APR
– ECU synergy
– PalpationLove the pictures in the articles.
Subjective:
– MOI and events surrounding the time of injury
– Imaging (XR)
– Paresthesia
– Weakness
– Hand atrophy
– How has he tried to manage pain for the past year? (bracing?)
– Bruising, clicking, popping,
– Golf specific questions (R vs L hand, driver/iron/putting/sand
– ROM limitations (pronation/supination vs flexion/extension)
– What is his training/competition schedule for golf?Objective:
– Observations (atrophy, swelling, overall posture)
– C/S screen
– Peripheral nerve vs nerve root (ulnar vs C8) tests
– Local, proximal and distal soft tissue palpation (FCU/ECU/pronator teres)
– Palpation (hook of hamate / pisiform / TFCC / ulna)
– Joint assessment: DRUJ, radiocarpal joint, mid-carpal, inter-carpal, MCP
– MMT: wrist/hand/elbow
– Special tests: ulnar foveal sign, ligamentous stress tests, TFCC compression, Wartenberg, froment, spurlings, hand and thumb handheld dynometer)
– Golf swing analysis (backswing, impact, follow through positions)
– Carry / lift 5# dumbbellMy guess would be a potential hamate fracture vs TFCC tear. My asterisks signs: location, competitive golfer, compression, swelling. I would want an X-ray to rule out a fracture before proceeding with treatment. You would think a fracture would be healed by one year, but if he is still having persistent swelling, repetitive impact with golf, and sensitivity to compression – I would still like to rule out a fracture. I would think potential short-term immobilization (brace) might be the best for this patient. I have not evaluated a wrist/hand in clinic yet, so I am not sure what would be appropriate. Despite my lack of experience, I like your take on it Matt – looking at the wrist/hand the same way you look at any other joint.
After listening to the last journal club and talking to co-workers, I realized that I do not have a very good approach towards managing a predominately biopsychosocial case. I typically try to fit everyone into a biomechanical category/pathology and treat from there. For example, I thought Jeff’s case was primarily facet driven when reading the case. However, I was missing a huge biopsychosocial component. Because of this I researched and found an article to provide a framework when evaluating, managing, and treating someone with disabling low back pain. The article is titled, “Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain” by Peter O’Sullivan. When a patient presents with a huge biopsychosocial component and chronic pain, the style and focus of my PT interview and intervention needs to change away from a biomechanical approach, but rather towards a cognitive functional therapy approach in my opinion after reading this article. I created an outline of this article that I can use in clinic. It highlights the multidimensional factors associated with low back pain including the modifiable and non-modifiable factors for influencing pain and behavior. But more importantly this gives me a framework for interviewing, assessing, and managing an individual that I might encounter with chronic disabling low back pain. This article also gives three patient case examples on Cognitive Functional Therapy which I thought were helpful.
Jeff, looking back at your journal club case, I feel like the interview strategy proposed in this article could provide a framework for managing that challenging patient.
Erik, I really liked how you managed the patient’s pain beliefs and other emotional/social factors that were associated with her injury.
Jeff, is / has the patient being seen by someone for her PTSD? That’s awesome that you blocked off time for her to read the pain book. How do you think you could change her belief about pain?
Matt, I feel like I have done something similar in clinic. I always want to be hands-on, especially after our weekend courses to practice techniques. However, a hands-on approach might not always be best and may encourage dependence like Jeff stated. I liked how you switched your focus in clinic towards her goals of walking while also addressing her pain.
Any thoughts on the article I posted?
For someone like me who has a difficult time talking about emotions, I thought this article was helpful to give me some guidance towards opening up a potentially giant/scary biopsychosocial door.
Erik and Matt, I really like your takes on patient education.
1. Based on the subjective findings, what are your immediate differentials?
– Acute on Chronic/degenerative discogenic (L4/5, L5/S1)
– Acute on Chronic/degenerative facet (left lumbar)
– Myofascial referral from lumbar musculature (lumbar multifidus, erector spinae, QL)2. Based on the objective findings, are there any other tests that you would have performed?
– Common positions at work?
– Dermatome
– Seated compression
– Traction
– Slump
– Prone torsion test
– Prone press up
– SIJ cluster
– FABQ
– T/S screen3.What is your primary hypothesis?
-Acute on chronic left lumbar facet pathology
4. What interventions would you have performed on the first day?
– Education for positions of comfort at home and at work (right side-lying with pillow under hips, knees to chest)
– Gentile active ROM exercises (forward table slides, quadruped rock backs, knees to chest supine)
– Introduce chronic pain talk (but not too much)5. Would this be a patient you would perform manual therapy with, or would you keep your interventions all active? If you did any manual therapy, which technique would you choose?
– I would start with manual to try to gap the left lumbar segments in side lying
– Maybe light massage for soft tissue restrictions / giving non-painful input to brain to lumbar region
– Potentially manual traction
– I feel like this patient could very easily not tolerate manual interventions in which I would switch to mostly active interventions – starting in gravity minimal positions.1. Based on the subjective information presented above what are your top three differential
diagnoses? (Ranking order)– Myofascial referral (glute med/lumbar multifidi)
– SIJ dysnfunction
– Pelvic floor dysfunction
– Lumbar clinical instability2. Based on the objective information presented above what is your top clinical diagnosis
and why? Does it follow a clinical pattern?– Right glute med tendinopathy
o SL squat deviations and pain
o SL stance pain and unable to stand for 30 seconds
o Pain with palpation of glute tendon and muscle
o MMT: hip abd and ER pain and weakness
o Negative lumbar and SIJ tests3. Is there any information you would have asked during the subjective examination or
collected during the objective examination?– Ober’s test
– Pelvic floor special questions
– Birth questions (i.e. complications?)
– Previous hip pain, pregnancies, back pain?
– Imaging?
– Chiropractic treatment interventions
– Prior history?
– SLR
– SLR with compression
– Prone instability test
– Beighton scale
– Prone LE activation4. What would have been your exercise prescription and educational interventions for day
one?– Positions to avoid for glute tendon compression
– Sleeping positions
– Frequent and prolonged clamshell isometrics in side lying, different angles1. Based on the subjective information presented above what are your top three differential
diagnoses? (Ranking order)– Lumbar radiculopathy (L3/4)
– Complex regional pain syndrome
– knee ligamentous injury (PCL) – dashboard injury2. Based on the objective information presented above what is your top clinical diagnosis and
why? Does it follow a clinical pattern?– L4/5 Lumbar radiculopathy (discogenic, annular tear?, extension bias?)
o Subjective
– Young
– None specific knee pain
– Recent MVA
– Pain referral pattern (knee, hip, back, ankle, foot)
– Changes with WB
– Worsens with LE extension in seated (slump)
– Valsalva with urinating ?o Objective
– Myotomal, dermatomal changes
– Lumbar motion recreates same pain in LE
– + Slump for same pain
– + CPA radicular and local pain
– + POE3. Is there any information you would have asked during the subjective examination or
collected during the objective examination?– what surgery is she schedule for?
– What other imaging has she had if they are planning on surgery?
– Injections / anti-inflammatory medications?
– Tibiofemoral joint mobility / laxity
– Functional LE tests
– Color of LE
– Distal pulse / capillary refill
– Calf/knee/ankle swelling measurements
– Lateral shift posture?
– Seated flexion overpressure
– Quadrants for spine
– Valsalva
– Prone torsion test
– SLR
– Saddle paresthesia,
– t/s mobility4. Rank by % her origin of Pain: central, nociceptive, neuropathic.
– Nociceptive 60%
– Neuropathic: 25%
– Central: 15%5. Rank which of these you would want to provide during IE: Education, Manual, Exercise.
Why?1. Education
2. Manual
3. ExerciseI would only provide education with this patient. First to go over exam findings and your plan of care. Second, provide education on positions to avoid and positions of comfort. Based on her irritability, I would want to see how she tolerates the exam before providing exercise or manual.
6. How would you educate the patient regarding our findings and her upcoming surgery? If this
means a suggestion of no surgery, how would you address the doc?– Depends what surgery and where
– I would communicate your subjective and objective asterisks
– See what his thoughts were and why
– I don’t think I would tell the patient that she shouldn’t have the surgery. I would like to see the MD’s take on the situation first. I would communicate with the patient on where you think her symptoms are coming from and why, what you can do to help, and will try to communicate with the MD prior to her next appointment.1.Based on the subjective findings, what are your immediate differentials? Do you ask any more probing questions?
– Impingement syndrome, RC tendinosis, ACJ arthrosis
– Patient goals
– Any change in lifting or activity (frequency, intensity, type, especially around the time he started to have pain)
– What is his typical exercise routine (i.e chest day every day?)
– Gun posture
– Pain at work?
– Imaging2. Based on the objective findings, are there any other tests that you would have performed?
– Seems like you hit everything, pretty awesome you had him bench 275 #
– Dumbbell press to compare to bench press, also look at other exercises performed at gym
– How does he lift objects to the side (impingement positions?)
– AC joint mobility
– Pec flexibility
– Neuro? If radic was on your differential3.What is your primary hypothesis?
– Same as yours4.Do you agree with the order to have the “functional testing” after the rest of the exam? Would you have done this day 1?
– Yeah, I agree with your order. If they patient had low irritability/severity, and his main goal was to return to bench pressing pain free, I definitely would have tested that. I think doing the objective tests first like you did, helps to eliminate any large structural deficits so that you feel confident having the patient perform a bench press without injuring the patient.
5.What interventions would you have performed on the first day? More/less/different MT? Different exercises? Let me know your thoughts.
– Gym and exercise modifications (decrease intensity, frequency, active rest)
– Continue nsaids – if irritability is high
– Foam roll thoracic ext and pec minor/major stretch
– Scapular retraction exercises – show things that he can do at the gym
– I typically run out of time on my evals, so I don’t always perform manual interventions on the first day. The manual exercises you did seemed to help address his specific limitations. Maybe thoracic spine manipulation?I did not read the “denies/negative” title so please ignore my cancer related comments. After re-reading the case along with Erik and Matt’s comments, the primary pain driver to the patient’s recent symptoms seems to come from the cervical spine specifically in the right C5/6 region.
Erik, what type of nerve gliders would you give this patient on the first day?