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1.What are your top three diagnoses based on the subjective information? (ranking order)
– c/s radiculopathy
– 1st rib dysfunction
– Rotator cuff tendinopathy2. Based on the subject info, what would be your top priority objective tests and why?
– rule out non-MSK due to hx of cancer and insidious onset
– Differentiate between shoulder and cervical spine
– radiculopathy cluster3.What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
– Upper crossed syndrome (posture, job, (SCM p! with activation / stretch, better with unloading), tight post capsule, no MOI, negative radic, wide range of pain, cuff related weakness with minimal pain)
4 What subjective and objective information do you feel is missing and would have been helpful to assess with this patient? (Key information, keeping in mind this is a one hour eval)
– 1st rib tests
– scapular exam (posture/palpation/movement/associated strength/re-positioning)
– work related ergonomic questions
– patient’s age
– cancer related questions
– cranial nerve exam
– dermatomal testing / DTR / UMN
– imaging
– patient goals5.What would you test in the next follow-up treatment session?
– 1st rib
– scapular vs cervical spine driven with upper crossed syndrome6. What would you have given patient for her initial HEP?
– posture education
– ergonomic recommendations
– seated scap retraction
– posture stretching / relaxation techniquesVery interesting article. “PT does not result in greater improvement in pain or function compared to sham treatment, raising questions about its value for these patients” – pretty strong statement, and in JAMA of all places.
The conclusion from this study was very frustrating. I then became very biased and tried to find how this article could be wrong about PT.
My first thought was to compare our clinical practice guideline for hip OA to their protocol. The JOSPT CPG revision of hip pain and mobility deficits – hip OA came out in 2017, while the JAMA article was posted in 2014. Keeping the time difference in mind, the JAMA article used interventions that were similar to the revised hip OA CPG. For example, the CPG has strong evidence supporting manual therapy, and flexibility/strengthening/endurance exercises; moderate evidence for patient education, functional/gait/balance training, and modalities (ultrasound/heat). The JAMA PT group focused on manual therapy, flexibility/strengthening, and education while the sham group had inactive ultrasound…So that didn’t work.
Although, the JAMA article focused on research supported areas (i.e manual/exercise/education), the way they carried it out was different than I would have expected. I thought the manual approach was appropriate which included mandatory techniques of long axis distraction with thrust, seat belt mobilizations, IR in prone, and soft tissue massage. This not including other optional manual hip glides, distraction in prone, manual stretching, and lumbar spine mobilization. The interesting part was their exercise portion. All exercises were instructed to be performed as a home exercise program. The target muscle groups were appropriate, but the exercises were not really performed in clinic but rather to be performed at home. We all know patient compliance is very hard to achieve. How they measured adherence was through self-reported measures such as a “log book” and “mailed questionnaires asking participants how many days in the past week had they performed their HEP.” Seems very trusting for a study that states, “the rigorous methodology is a strength of our study.” That would be like a teacher asking you to write down if you did your homework without actually checking to see if you completed your homework at all, but that is just my opinion.
Overall, this article does not really change my practice towards hip OA management. I would be interested to see if they changed their exercise implementation to a more supervised approach, would the results still be the same.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966457/pdf/1471-2474-11-238.pdf – protocol
I have not encountered anyone thus far presenting with this condition. However this article gives a nice framework of examination and treatment of an individual presenting with these symptoms. The diagnosis of “athletic pubalgia” has a fairly broad definition: “pain in the groin, medial thigh, lower abdomen, or public region that presents in athletes.” Much like many syndrome diagnoses in physical therapy, this is a diagnosis of exclusion and has a broad presentation. A recent JOSPT article (attached below), may help improve the specificity for groin related pain through examination and evaluation by breaking it down into (adductor, iliopsoas, inguinal, pubic, hip, FAI, or other related groin pain). Although, athletic pubalgia seems to have a specific population associated with the diagnosis (young males involved in high intensity running/cutting sports). The most prevalent theory is a biomechanical imbalance between the structures that attach to the pubic bone in combination with playing a sport that involves these particular structures. A study that the authors reported found that an athlete is 17x more likely to experience an adductor muscle strain if there adductor strength is < 80% of hip abductor strength. Other studies they reported on found that rectus abdominus strength or delayed contraction of transverse abdominus resulted in increased risk of injury in this region. I like how the authors propose an intervention sequence and categorize individuals based on pain, ROM, and strength initially, then gradually progressing to address local, then regional contributing factors. Overall, this is a very helpful clinically based article to help diagnose and treat athletic pubalgia.
Jeff – I think the main reason they perform at neuro exam, is because this is a diagnosis of exclusion. It also helps to take off anything scary on your differential list. Interestingly, the authors state that “the patient with AP will most often report insidious onset or non-contact related unilateral pain in the adductor region and/or lower abdominals.” An insidious onset would also make me want to fully rule out neuro.
Casey – yes, that seems surprising how early your patient is returning to running / agilities. Did you find any strength or ROM imbalances in your patient that was consistent with what the article stated for this patient population (i.e. hip abductor vs adductor strength)?
These two articles are great because of their clinically relevance and applicability. About two months ago, I evaluated 30 y/o male with lateral hip pain who presented with symptoms most consistent with gluteal tendinopathy. I was not sure what to do after the evaluation, so I did some research and actually found this JOSPT article which helped me tremendously. On my initial objective exam, the main objective findings for me were the pain with palpation, resisted abduction, and ober’s test – yet this was not very provocative. I did some single leg assessment (single limb stance for 10 seconds and single leg squat – only looking for pain). Both of which were negative on the exam. But after reading the article I realized I need to be more specific with my single leg tests. The first follow up session, I tested single leg stance for 30 seconds and single leg squat looking for pain and deviation – which the pt had positives with pain and deviations that worsened with increased repetitions. That follow up session I cut and pasted the pictures from this article about positions of compression and gave it to him, which really helped him because he slept in the side lying position with weight over the greater trochanter. We talked about positions to avoid while at work or home.
Treatment wise, the isometrics made the biggest change in my opinion, mostly with pain. I do not think I gave enough reps based on what the article recommended, but it still had some good changes (4×45 sec, 2x day, SL clamshell isometric with band at different hip flexion angles). I struggled with managing exercises between the isometric phase and single leg phase. The second article would have been really nice for developing a better treatment progression. I tended to go too fast too soon with single leg activities which would increase the pt’s hip pain days following. But overall, this JOSPT article was great and super helpful. I feel like I would have spent too much time trying to massage the glute med/min region and clam-shelled him to death with reps versus managing this like other tendon pathologies, with isometrics and gradually progressing load.What are your top three diagnoses based on the subjective information? (ranking order)
– Myofascial strain of posterior thoracic and lumbar musculature
– Local discogenic pain thoracic, lumbar or cervical
– Dural/neural irritability in thoracolumbar regionWhat is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
– myofascial strain of thoracolumbar region with potential clinical instability of lumbar spine. The patient has inconsistent pain symptoms at this time that would be consistent with discogenic or facet related pain. The reason I think it is more myofascial pain is because the patient has pain in multiple directions, increased hypertonicity/guarding, improves with posture change, active hip extension is painful but not passively, tender to palpate soft tissue, deep ache, limited trunk movement with movement. I think there might be an underlying clinical instability based on hypermobile and painful lumbar segments but would probably be hard to tell at this point.
3. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient?
– Any imaging? If so what kind.
– Fabq ?
– who gave her the lifting restriction?
– cranial nerves
– upper cervical ligamentous stability
– lower cervical pavim or PA’s
-rib spring
-what is her current stress level and stress level at work or home
-prone instability test
-scapular mobility / strength
-lumbar or thoracic resistive testingHow would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this patient regarding prognosis?
– I would say something along the lines of: you have had a couple of traumatic events within a short amount of time, and it is normal to have pain afterwards, based on my exam there doesn’t seem to be anything too concerning with red flag symptoms and that your back is strong, at this point your muscles are very irritable, which is normal after an injury as they try to protect the area, but now the muscles are still very tight and get irritated when they are stretched like when your bend forward to tie shoes or slouch.
– I might have concerns with emotions and fear and how that might limit progress. However, if everything for red flag is negative, then I wouldn’t have any major concerns.5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie regarding patient education, manual therapy techniques, therapeutic exercises, etc.
– I would focus on decreasing her pain levels with either light movement through both lumbar and thoracic regions (cat/camel or child’s pose), and add manual massage or light mobilizations to calm the system down. Gradually progressing towards her work/home related goals
That is definitely a hard question to answer because the patient makes a valid point. Attached is an article that BJSM published not too long ago titled, “Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline.” I really like this article because it has some nice graphics that are researched based but also easy to explain to patients. One graphic compares the long term benefits, short term benefits, and short term harms of conservative vs surgical management. Their study found that there was no difference in long term benefits in pain or function (1-2 years) between the two approaches. Arthroscopic surgery had more favorable results in short term benefits (< 3 months) in pain and function yet arthroscopic surgery had increased harmful events such as DVT and infection compared to conservative management which had no adverse events. Not to mention the cost of imaging and the surgery itself which is much more expensive than conservative management. This article is somewhat biased towards conservative management in my opinion but it does give valid points that we can mention to patients with this diagnosis. So going back to your patient’s question Casey, you could potentially show him that yeah you might feel better in the short term with surgery but there is no different in long term benefits and there is a higher risk of adverse events with surgery. As for the exercises every day comment, you could say that you don’t have to perform the exercises every day once your function/pain is normal but you’ll know how to self-manage your symptoms in the future.
Jeff and Matt, you guys make great points.
This article would have been great for a patient I evaluated 2 months ago. The patient stated “if I have a tear in my meniscus, why am I coming to physical therapy instead of surgery” at the beginning of the session. Below are his MRI findings (which the patient brought with him to the evaluation). After the subjective and objective exam, the patient presented with symptoms consistent with meniscal and MCL involvement.
MRI left knee:
1. “Free edge tear of the posterior horn of the medial meniscus which is smaller than normal, likely related to a prior tear but no displaced fragment identified,
2. Discoid lateral meniscus without tear
3. Sprain vs low grade partial tear of the ACL
4. Partial tear of the semimembranosus tendon with muscle strained associated with posterior oblique ligament injury,
5. Strain of the MCL with probably tearing of portions of the coronary ligament “I stated to the patient: Conservative management with physical therapy has similar outcomes to meniscal surgery, and if we’re not making any progress, then I would refer you back to the doc. Even if surgery is appropriate, those who have conservative management prior to surgery have better outcomes anyway, so it’s a win-win. But we need to at least try PT for a minimum of 6-8 weeks to see some changes.
Many of the physical therapy related journals recently have published findings stating that conservative management has similar outcomes to meniscal surgery. This article is really nice to compliment the PT journals who have lower impact factors (i.e. BJSM impact factor 7.8) to JAMA which is 47.7. This is definitely a nice article to back up our recommendations for pro-PT versus the patient taking our word for it. I would use this article in the future for this type of patient to help patient buy in to conservative management. I will still bring this up to this patient when I see him next time.
Any thoughts on this patient or patient education?
Luckily, this evaluation was during mentorship hours, so Mike was able to help me through this case.We tend to see a decent amount of younger kids at our clinic (high school and college). I agree with your point Erik, it can be very challenging when communicating about pain with this population. I have found that it tends to be even harder for younger patients, especially if the parent is in the room answering the majority of the questions. But this is interesting. The older population can generally tell you very specific details about their pain such as location, description, time of day, etc. However, when I ask younger patients about their symptoms, they typically give me a blank stare and don’t know how to put into words what they are feeling. What I have been doing recently, is starting to ask less about pain and rely more on my objective exam. I have been asking less subjective questions and starting my objective exam earlier to get an idea of their movement quality which can tell you a lot more than what they are telling you. As the objective testing goes along, I will ask follow-up questions related to their primary complaint. This has helped me some, but I have also run into a problem of the young patient not telling me everything, and I find out something different from the parent. Still working on this, any tips would be helpful.
1. Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
– what type of imaging and positions, any recent imaging?
– what helped / didn’t help with previous PT treatment
– what are the patient’s thoughts on manipulation
– instability red flag questions
– Bone density testing?
– tinnitus, balance, mood ?
– occupation specifics – demands / how long has she been working there?
– ADL’s around the house that still struggle with?
– what activities does / did she enjoy? change with pain?
– What has changed in the past few months to increase fear of driving or has that always been there?
– what type of exercise / stretching / massage location and technique help decrease pain?
– sleeping position and quality
– joint position error testing?
– balance (single leg / unstable surface / eyes closed)
– CCFT ?
– testing rotation with upper trap in slack
– cervical quadrant vs motor control testing2. Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?
– Yes.
– MOI, very broad symptoms – not just a joint issue
– chronicity, fairly constant,bilateral trigger points in upper shoulder girdle, cervical endurance deficits / motor control deficits, pain with involved cervical segments, increased biopyschosocial / kinesiophobia3. Do you see any red or yellow flags associated with this condition?
– Red: osteoporosis with mechanism, instability / laxity ?
– Yellow: fear, avoidance, perceived disability4. What concerns do you have about the patient’s current presentation and previous treatment?
– Current presentation: worsening / no change
– Previous treatment: manipulation, no change in symptoms, frequency ? 2x/year ?5. What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
– Depends what her perception of what worked in previous PT sessions, take into consideration
1. education of pain, prognosis, plan of care, reassurance
2. symptom / pain reduction with manual therapy
3. active motion
4. aerobic exercise
5. relate exercise to patient goals (mimic driving)6. Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?
– manipulation (osteoporosis, older female, fearful)
– immobilization collar (chronic, increases fear)
– heavy resistance training (movement/endurance/pain relief are goals)Placebo factors – Dhinu’s Article
Things I need to work on:
– I tend to ask about pain way too much. For some patients such as those with chronic pain, asking about pain constantly doesn’t help your differential and it also has a nocebo effect. Mike and I have talked about this during residency time. Using phrases such as “does that change anything” rather than asking “was there any pain” during an exam should help avoid the nocebo effect and take the focus off pain.
– I struggle with making a clear prognosis during an initial evaluation. I tend to avoid telling a patient a prognosis because I am just not sure what their prognosis is due to lack of experience. When I do give a prognosis, I have been trying to use statements that “under promise and over deliver” vs the opposite – similar to restaurants giving estimate wait times. But I feel there is a fine line with this because you also do not want to tell the patient too long of a prognosis that they don’t come back.
– Tailoring plan of care to meet age and gender perceptions (based on the article) such as males want to see outcomes, females want organization and communication, while older adults like to know about access to services and effective communication.
– I also have tried to use more positive verbal instructions, especially with manual techniques this week. I have tried to use something like “most people say this feels good” vs “let me know if this is too painful.” I think this has helped patient buy-in.Work Environment – AJ’s Article
– I think there are common themes with all patient – therapist interaction articles. The big thing that I take away from this article, is it makes me consider what the patient is going through from their perspective. Imagine yourself, sitting in the waiting room with some type of injury. You are in a vulnerable state. You’re missing out on things you’d rather be doing (working making money, playing sports, etc). You are relying on a PT to get you better. How would you want to be treated? If we can be empathetic, answer their questions about what’s going on, explain what you can do to fix it, explain the process behind it, and be flexible this should lead to favorable outcomes.Side note: PT’s at our facility are now required to wear royal blue polos every day due to change in company…I wonder if our patient perceptions will change since most of the articles support clothing that is either lab coat, tailored clothing, tie, or other professional clothing.
When I have a differential diagnosis case, most of the time I am trying to identify the tissue at fault and/or movement pattern that might be leading to their chief complaint. During the subjective and objective examination, I am clustering information to fit a certain tissue/category. When I finally (hopefully) get to my conclusion of what is going on, I then realize that I cannot simply tell the patient what I am thinking is the root of their problem because I am worried about creating more fear/harm.
For example, I recently evaluated a young female who presented with mid/low back pain. After my evaluation, I reached a decision that her symptoms were most consistent with clinical lumbar instability, similar to low back pain with movement coordination impairments. Somewhat happy with my examination, I then realized that I cannot tell my patient that I think she has clinical instability of her lumbar spine, for obvious reasons. I ended up saying something along the lines of: based on my exam, there are some areas that are a little tight/stiff (T/S) which is causing increased stress/demand/movement in other areas of your body (hypermobile/painful lumbar segment). I was pretty vague and found myself talking too much trying to explain myself, which I think confused the patient. I think the main reason I did this was because I did not know what to say. This article is nice because it gives alternative words such as for this case, using words like “needs more strength and control” instead of “instability.” Sometimes I find myself over explaining things to patients. I don’t know if it is because I am trying to reassure myself of my findings or to sound knowledgeable to patients, I’m not sure. But does it really matter anyway? The only thing the patient wants to know is if you can help their problem so that they can get back to what they were doing previously. So, I feel like less is sometimes more – at least for patient explanation, maybe not for documentation.. Patient education is definitely an area that I need to work on.
Jeff, great points. I definitely feel like talking to patients who already know their imaging findings can be the most difficult. I like your point of keeping the patient’s point of view in mind.
Very interesting comments.
I think we all use the placebo factor in patient care. In my opinion there are two types of placebo: intentional and unintentional. Unintentional placebo would consist of what Jon was talking about, dressing professionally, body language, eye contact, appearing invested, listening to patients, mannerisms and overall appearance. One older study looked at how physician physical factors influenced willingness to comply with exercise recommendations. They found that patients with higher education and higher income levels could be positively influenced by a physician being of appropriate weight, a regular exerciser, and non-smoker. While female patients could be positively influenced by physicians being well groomed, well dressed, accessible, and good listeners. https://www.ncbi.nlm.nih.gov/pubmed/8673568
Intentional placebo, I would consider to be using placebo knowingly for your benefit. The JOSPT article “Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation” does a great job exemplifying placebo. This article mostly focuses on specific words, but words are very powerful. The article opens with this quote, “words are, of course, the most powerful drug used by mankind.” This is so true. It is sometimes tough for me explaining imaging findings to patients, when they have already seen the results explained by the doctor. These patients hear “disc bulge, instability, bone on bone, etc”.… rather than “bump/swelling, needs more strength and control, and narrowing/tightness – respectively. I try to use placebo words with patient education but sometimes I still struggle with changing my clinical dialect. Some words may not sound harmful to us as PT’s but that same word may be taken differently by the patient.
https://www.jospt.org/doi/pdf/10.2519/jospt.2018.0610?code=jospt-site
Improving my clinical reasoning is one of the reasons why I wanted to pursue an orthopedic residency – like most of you all. The case example in this article demonstrates how using a form like the SCRIPT can assist with clinical reasoning with a complex patient. The form provides a framework that you can refer back to during or after an evaluation to breakdown the complex patient. This seems especially helpful for those patients with many impairments/complaints that can fog your evaluation findings. The clinical reasoning form also provides a pathway to choosing specific interventions for your patient rather than choosing interventions that are general so that you can hopefully provide faster outcomes. I really liked how the clinical reasoning form shows the importance of test and re-test. Either with testing hypotheses to reach a specific diagnosis or with interventions so that you are using interventions that are showing change. Using a tool like the SCRIPT in combination with the clinical knowledge of a mentor should improve our clinical reasoning by the end of our residency.
Haha yes, I can definitely relate to you Casey. I feel like sometimes with patients who have so many impairments, I find myself wanting to fix them all at once. This results in an unorganized POC which can be sporadic and exhausting for the PT and the patient. Hopefully using a clinical reasoning form will guide our treatment approaches.
Nice post Tyler,
1. I would also assess her running mechanics if time allowed for it during the evaluation. I would also be curious to see how she performs a lunge and bilateral squat at the gym.
2. Due to the patients hyperextension and inferior tilt of the patella, it could be placing a lot of stress on the infra patellar fat pad, especially if she stands statically with her knees locked at rest. I have seen success with McConnell taping by placing a superior tilt on the superior portion of the patella in combination of scrunching up the fat pad with an inferior to superior pull surrounding the patella bilaterally. This could help with unloading that fat pad and decrease pain levels. See how she does functionally (running and step downs) with tape on afterwards.