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Yeah, that’s a good point Jeff. Cam, are you thinking along the lines of how long the procedure was, or if he was addressing the molars vs incisors?
I bet her history of MVA can be a good place to get some of this type of information… how she sought care afterward, the type of care she received, the type of care she felt like was successful or unsuccessful. More info on her experience with this event, participation in sports, and injury could be great gateways.
1. List your differential diagnosis after the subjective exam. Does this change after the objective exam?
Subjective:
– ATFL/ CFL sprain or rupture
– CAI
– perennial synovitis
– impingementObjective:
– CAI with peronneal synovitis2. List any yellow or red flags you’d consider this case.
– Apparently switched via Direct Access to visit a different PT company after experiencing pain with a different PT
– Passive approach to easing factors
– She notes at best being in 4/10 pain (I.e, constant pain), but only reports having dull ache intermittently and occasional high grade sharp pain
– avoidance behaviors3. Are there any components of subjective or objective exam you would have included during the IE to help clarify your DD list?
– How deep were her squats? That requires DF, but these weren’t painful…
– Was SL squatting painful?
– Subj: Clarify what is her “at best 4/10” pain when she only intermittently has dull ache
– Subj: What type of dance history?
– What part of walking is painful?
– Why is driving painful, which requires primarily DF? Is this only on the table after she’s been flared?
– I’d wonder what her DF tracking looks like… If the TC jt is hypo mobile, does it track her into EVR?
– What depth palpation elicited her pain? Is the tenderness a recreation of her Ache or Sharp sx?
– Posture: She pronates… can she actively supinate?4. What would be your manual, exercise, and educational interventions are for IE? Does her past treatment influence interventions during day 1?
– She has extensive history with PT, but I’d want to check in on her understanding of the problem at hand. It doesn’t sound like she believes the prior PT knew what s/he was doing, so I’d want to get on the same page here.
– Use the Education piece to address her apparent fear of certain activities
– Manual: TC mobs to tolerance in either OKC or CKC with transition to HEP
– Ex: Open and closed chain weight bearing proprioceptive challenges that incorporate AROM to toleranceHow about some red flag clearing questions, like questions that would give detail to items like emotional stress or instability? She’s a 26yo PhD student, so stress seems reasonable, and information on a mechanism beginning her initial pain episode can be helpful.
Assuming it’s primarily TMD mechanical, what about questions about where in the process of opening is the click and if it locks?
That’s a good point, Jeff.. I wonder if it’s in part because the thumb is a joint that can easily be self-manipulated by the other patient hand? That gives the patient access to the manual tx… and they can already do the exercises.. so I think you’re right to wonder about the education component.
Absolutely, Jeff. That’s why I’ve appreciated journal club — it’s helped me consider the applicability of the article to the patient.
Love this! It all has individual value, and it’s important to not overestimate an RCT just because of where it falls on the evidence pyramid.
I love relating the CMC joint to the shoulder joint, since they both lack osseus stability and are highly mobile for it.
The theory of CMC OA occurring from degenerative ligamentous laxity (requiring inc active stabilizers) reminds me of secondary shoulder impingement pathology’s “Silent Subluxation Cycle” process… am I way off on this?
The article demonstrates both statistically and clinically significant improvements in outcomes when the interventions (patient education + splint + HEP regime) are patient-centered.
With this in mind, I’ve jotted down a few considerations for our 39yo mom:
– Pathology:
POSITIVE – chronic but relatively short duration (~1yr),
POSITIVE – sounds volume-dependent (gotten worse as activity has increased), so potentially an opportunity for modification
NEUTRAL – moderate degeneration,
NEGATIVE – it’s worsening– The person:
She describes a very busy life (too busy for surgery), and one that is potentially ramping up in activity volume. Her stress appears high… both of which could potentially delay a simple, quick prognosis which is dependent on consistent adherence to a direct prescription from a clinical practitioner.My prescription:
Exercises: The article highlights 58 participants who completed the HEP 1x/ day, compared to 2 others who completed the HEP 2-3x/day. The exercise prescription also considered their tolerance to the exercises, partially related to their pain levels and irritability. There’s no specific case information to base a decision on, but we know that she’s currently tolerating a high volume of daily activity without specifically mentioned need to stop or address it throughout the day. With these in mind, I’d feel more confident prescribing the exercises 1x/day.
Management: I’d be really keen on providing a heavy dose of education day 1 and swing that into a discussion on potential compensatory strategies, such as using an assistive device to open jars when making meals or carrying bags on her shoulder when possible rather than gripping them with the affected hand.
Splint: I might initially prescribe a hybrid brace (13 participants found success across the article) to accommodate her need to perform a variety of duties throughout the day. The mean time spent wearing the brace was ~9hrs, so a hybrid brace would make it more easy to adhere to as a prescription.
Another reality here is that orthoses aren’t an intervention for me to weigh heavily, as the study demonstrated a poor relationship with a large enough orthoses-related VAS change for a DASH reduction meeting the MCID. If necessary, we could always transition to a more rigid brace.The study recorded changes across a 6-week timeline, which didn’t demonstrate adequate gains in pinch strength and the article suggests that more time may be required. (It should be noted that the average participant age is in their 60s, whereas our patient likely has a quicker prognosis for tissue growth since she’s still in her 30s). Even so, the study shows that pinch strength and pain levels are most highly associated with functional gains and patient satisfaction, so this is an important variable to see success with.
For this patient, I’d expect a longer prognosis (potentially 2-3mos before considerable gains are observed). Some studies referenced in the study measured gains across a 1-year span, so I could see a motivated mother in her 30’s seeking an alternative to surgery meet gains quicker. Other things I might consider to help her along are the suggestion of a journal log (aiding to hold herself accountable) and a self-CMC distraction+mobilization technique we’ve learned to be clinically successful.
I don’t have much anecdotal information to guide my thought process, so I’m really interested in what everyone else’s take on my prognosis compared to their own might be.
I love how Karen explains her pain as a journey. It can be easy for me to be off-put as a patient aggressively describes their pain experience haphazardly between the ages of 2 – now as a 63 year old adult. How often do I ask myself not only who this person is but why?
The author was once a “confident, strong woman,” but she transitioned into one who is “timid… [and] unsure” as the pain “took over” her life. Why did my patient get to the point of feverishly describing their pains the way they chose to? Karen’s descriptors as “consuming” and taking over her life make me wonder about chronic pain’s effect on a patient’s locus of control.
Was it the fear that ate away at her innate personality, or more so the feeling of ineptitude as a physical therapist to defeat her own musculoskeletal pain? I can imagine that strong, nagging negative emotions can break through the floodgates and begin to overwhelmingly dictate their self-talk and personal ego – changing maybe not who she is but how she is.
It’s my belief that pain, when experienced over longer periods of time without relent, can entirely change the presentation of a person. Wondering if other people agree, and how you all feel about our duty as a musculoskeletal expert versus having a responsibility to affect how this person is being as a result of chronic pain?
One thing that I like is how we as PT’s can use the DRUJ as an example in our practice. The strength of this joint comes from a see-saw effect, demonstrating balance in stabilization from an active source when passive stability is lost. How many patients have asked us “What can you do to help me, when I know the ___ (ligament, disc, etc) is damaged?” Can this help my education? How can I apply a generalized truth from the DRUJ to other joints in the body to better my practice?