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Love this article, Kyle.
I jotted down a few notes about the methods that I felt should be considered before discussing the results and conclusion:
– Only ~12 of the 60 participants were actively seeking treatment.
– The authors don’t dichotomize SPS into Primary or Secondary impingement, so patients who “fit” an umbrella impingement characterization may actually require a greater manual focus at the glenohumeral or AC joints to address associated extrinsic factors. (I wondered why subjects were excluded if they had a + Apprehension test when that is a portion of the proposed algorithm?)
– Additionally, the inclusion criteria allows the possibility that the subjects don’t fit the test cluster for Subacromial Impingement Syndrome ( + Hawkin’s Kennedy, Painful Arc, and Infraspinatus test VS. Painful Anterolateral shoulder, + Neer’s, and shoulder ABD AROM of < 90deg).
– Finally, limiting the chronicity to 6mos may “decrease the likelihood of a RTC tear,” BUT the patient could also be a 60yo with a painful arc and have + Infraspinatus test (3/4 test cluster for RTC tear) thereby increasing the likelihood.
Batting points aside, I understand what the results indicate. A patient having a positive outlook is a portion of the test cluster indicating a cervical manip, and it’s been shown that the same perception on the outcome of the thrust will yield better thoracic thrust results. To me, this reiterates the power of perception. It’s possible that the TS really does hold the “cinderella zone” with powerful regional interdependence, but I feel what’s the most consistently supported factor is the power of perception (this point harks all the way back to week 1 discussion). So I settle with: No, not everyone deserves a thoracic thrust, but addressing the TS may still be a useful adjunct emphasis to more well-supported approaches in the literature.
I read your post a little earlier, and I’ve been trying a few opening lines this week. I’ve had a lot of success with “Why don’t you tell me what you think I should know about what brings you in.” I asked a new patient this yesterday, and she outright said “The doctor told me I have bone-on-bone OA in both knees, so I honestly don’t know why we’re going to do an exam if you’re just going to give me a cookie cutter exercise prescription.” Boom, a boat load of talking points to start the session and not be bombarded with later on. It was such a nice segway early on without having to run my head into this halfway through my examination.
Try it out!
Casey, I love the excerpt you used from article to get a better idea of the TFCC’s relationship to its surrounding soft tissue structures. From the information presented, I’m generating a different conclusion. The explanation says the TFCC is stressed when the muscles are fatigued, but he’s not fatigued necessarily when he’s picking up his bag or if it’s the first repetition of a push-up, for instance. More specific information about the activity limitations would obviously sway the needle more accurately.. Would you mind providing a link to the article referenced?
Further, I’d be uncertain that compression vs distraction testing is as useful as we hope. Push-ups and chest press provide compressive load, however if the theory is that use of surrounding soft tissue is lacking then picking up a golf bag should generate a distracting force… Gripping is definitely a consistent factor in his functional limitations, as is pronation. Pronator quadratus and flexor digitorum profundus travel along the ulnar aspect as well.
This is a really interesting blog, and it’s well-timed for my personal reflection of my professional growth. I’ve been thinking recently about how I enter the room of an evaluation (a stranger) or a treatment session (someone I already have report with). I’ve wondered if it matters how rushed I was feeling 5 seconds beforehand, or what if it’s right after lunch and the first thing I do is yawn while sitting down? The blog is validating my curiosity, and it’s pushing it further.
Say a person has an inadequate view of what it means to have a disc herniation. Is it better to allow the person to continue to speak until their story dries out? I’d gain “ammo” to use later in my education and create a strong alliance, but I’d risk validating incorrect perceptions with apparent neutrality. I could do a stronger job of dictating the conversation, but I’d risk being just another doctor who’s expecting the patient to fit their agenda.
I love the the suggestion to just say, “Tell me what you think I should know about your situation.” I’d imagine it demonstrates a blank canvas for the patient to feel comfortable expressing their problem their way giving a strong sense of what the patient values and perceives is the crux of their problem(s). With this in mind, I may be able to answer my previous questions with the resolve to simply be a facilitator of their own narrative without dictating the outcome.
My big-picture observation is the incongruity of the direction of physical therapy practice and the direction of medical practice as a whole. It seems like there’s more and more emphasis of listening, being careful of verbiage used in front of patients, and letting a comprehensive subjective interview guide a well-established exam. On the other hand, medical practice as a whole is shrinking doctor-patient time. What’s obvious is that a more adequate subjective exam will lead to a more concise, more meaningful exam..
.. I’m curious what you all think is more important in the initial exam to gather, subjective (what the person feels might be occurring) or objective (what is definitely occurring) exam?
Interesting case here. I’d be interested in the following additional questions…
About the patient:
– Is he right handed?
– How long has he been golfing?
– Did he ever take a break when experiencing pain, or just push through it?
– What exercises during workouts?
About the sxs:
– Does he have concurrent neck or elbow pain?
– When does the swelling occur? Where? For how long?
– Easing factors? It sounds quick to aggravate, how quick to dissipate?
– What has the trend of his sxs been since initial onset over 1 year ago? No particular MOI it sounds like?
– More details on the location of his sxs
– History of Kienbock disease in his family?
About his function:
– Can he discern what part of the swing is bothersome? (at least which 1/3rd?)
– Is it the act of picking up a heavier object, or just carrying it?
– Does it matter how he weight bears? (e.g orientation of the wrist or forearm)
– I’d like to see him hold a golf club
– Clear: CS, nerve, elbow
– Observation of willingness to move, skin changes, and bony prominences
– A/PROM of wrist and pronation/supination
– Palpation of carpal and distal ulnar/radial joints, possible compression in cardinal or quadrant planes
– Ulnar foveal sign
– Grip strength
I haven’t come across many wrist/hand cases, but it sounds like from the 2 review articles that a well though-out subjective history and methodical objective examination to rule out structures is necessary for adequate diagnosis and subsequent treatment. I’d be interested to know what has worked with you guys to develop a clear picture for treatment!
Dr. Boissannault’s course did a great job of helping me think about the purpose of each red flag question. It’s my job to ask pointed questions, aimed at gathering information much like I would in my objective examination to guide my “treatment” (which may be a referral). “Recent infection” is a good example; I hadn’t thought of what constitutes a “recent” infection. It made me start to think more about the questions and what kind of information I’m attempting to gather.. what does the information tell me? These broad, often blanket-style questions are actually more specific than I’d originally interpreted and help shift the needle of a hypothesis much like a component of an objective exam might.
A good example is my 55yo male patient who’d finished his final round of chemo 6 weeks ago. He was reporting to my office with “LBP and Sciatica.” We spent 20 minutes laying out what stage cancer, location, surgical procedures, visit history/ schedule with the oncologist and PCP, and other all-of-a-sudden meaningful information to include in my initial examination. Nerve pain can be vague and broadly distributed, but it was important to me to demonstrate that his low back pain was mechanical and that his “sciatic” pain was reproducible with nerve sensitivity tests. 1 week in, I noticed his ankle was asymmetrically swollen affected side > unaffected. He hadn’t realized his leg had swollen until that moment and actually recalled thinking he’d gained weight because of the cancer when he’d felt like his pant leg didn’t fit as well about a month ago. Here, I was able to educate the patient on what to describe to his oncologist (and get an appointment sooner than his scheduled visit in 3 months).
Dr. Boissannault’s course and the attached article help me interpret more fluently the information at my doorstep; they help me speak to patients as a Doctor of Physical Therapy rather than Kinesiologist; they help me be a better case manager and provider for my patients.
I like to describe not so much the What but the Why to patients who have higher, more irritable, or persistent pain without acute injury. I’ve found success explaining the function of nerves, as you have Casey, and their role as vigilant body guards to alert us about potential danger. “Potential” is a key word here. That means it’s in part reliant on the nerve (and the person’s) PERCEPTION of what could be harmful. When “the system” is overactive, our body’s car alarm begins to turn on even against the brush of a leaf. (Possibly stolen analog).
Check out the attached article for a great example of this, which I’ll sometimes describe to patients.
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Jeff – I thought you did a great job presenting a multi-faceted case stimulating newer discussion.
When I picture this patient in front of me, the first thing I’d want to do is have her explain to me why she thinks she’s still in pain 12 years later. I think I’d be more effective at combatting her belief system… if I knew what exactly it was. To me, this is the crux of her self-limiting behavior, and I know I can weave in counter points if I know where the holes of her arguments are.
People are unhappy when their version of perceived reality differs from actual reality, and this person feels as though her life drastically changed from the moment a drunk driver collided with her car 12 years ago. I’d first and foremost demonstrate active listening with empathy. From there, it could be a good strategy to just show her all of the things she can do and begin to match current objective reality with her own sense of what she’s capable of. Rapport would be paramount, and it’ll be important to gradually gain information about what a typical day looks like in her world, her social support system, and her motivation factors.
By building a comprehensive picture for the patient, pain acceptance can gradually occur as her perceived reality begins to better match objective reality, and the injustice she clings to can gradually fade.
I have a 56yo mother, who was the captain of her tennis team before a competitor fell into her in the changing room and tore her ACL. My patient was/is furious, and suspects that this was on purpose.. This was her first actual injury, and it was evident her interpretation of Pain is extremely superficial and elementary (pain vs no pain, rather than a spectrum). She entered my office 6 weeks post-op (no PT) and was steadfast in her belief that, if she experiences pain, it means she’s tearing her ACL reconstruction.
My first 2 sessions with her were entirely listening to her reiterate how she’s furious she even has to be in PT instead of competing. All I did was accept and listen (Actually, I was gathering information). Her constructs of Pain, injury, perception of injustice, and her own interpretation of her prognosis were all poorly founded. The next 3 weeks were my turn, where I was able to systematically attack her beliefs with 1) education 2) goal setting 3) turning a negative into a positive.
My goal setting included both short and long-term goals. Short term goals were between-session goals that she was meant to obtain with her HEP (like demonstrate a steady quad set for 10 seconds, or achieve full active knee extension). Long term goals were my duty, like weight bear without crutches, walk, and move in bed without dragging her limb with her arms. The point of this was to show her that she was improving by participating in my plan (she knew her plan had failed — she came to me in bad shape 6 weeks post-op).
Turning a negative into a positive was something I “prescribed” on my own agenda by flipping the script. Whenever she described her own reality as down, hopeless, and unjust, I would explain to her that she’s getting expert attention to her physical well-being so she can be a better competitor post-op than she was with her previous training program (which was just a stair climber 5x/ week, anyway). Her competitive nature, which in part fueled her feelings of anger, became a tool I used as we train for her big return to the court.
She started to actually love coming to PT, as her reality went from one where she was forced off the court to one where she was focused on training to become an even stronger competitor. Her tx session subj report became more detailed and no longer her only indication of success or progress.
Great case. There’s been so much attention to accurately categorize our patients (movement deficit, radic, instability) that I wish the article made some mention of that for their subjects.
1. Based on the subjective findings, what are your immediate differentials?
I’d be interested where in the posterior L LE her pain refers.. Lower lumbar radic, Lower lumbar facet referral, Lower lumbar clinical instability. Disc doesn’t make my top list d/t painful sleeping prone, which should improve discogenic sxs.
2. Based on the objective findings, are there any other tests that you would have performed?
H & I testing for the quadrant, PIT or active paraspinal contraction with UPAs, Slump or SLR with UE extension activating abdominals, Seated picking up object from floor (though probably wouldn’t push this matter), and I’d be interested in which direction the car hit her from… on the front L? Would that push her into L SB and Ext, making her fearful of moving that direction?
3. What is your primary hypothesis?
Lower lumbar facet referral rises on my list d/t painful flexion quadrant R in addition to extension quadrant L
4. What interventions would you have performed on the first day?
** Education: Getting to know her belief system and what she feels is still the problem / what has been successful aside from opioids. Discuss reality that any “damage” likely healed by now, so we need to find the root cause and give her tools for independent management strategies. Her goals will be important.. does she even want to return to higher activity level, or is getting around the house enough?
She could probably benefit form the Explain Pain YouTube video as homework!
* Manual: What kind has she received in the past? Could be worthwhile, given your article, to provide a TS manip (or mid-grade mob).
* Exercise: Your exam shows that A/PROM hip flexion is normal… can we have her perform “bending” tasks from the bottom up? Maybe supine DKTC or Seated Cat (trunk rounding) with arms supported on knees? I’d be really interested in helping her really “map” out what she’s capable of.. it sounds like no one has ever guided her through movement after the accident, and she feels totally reliant on other people to keep her going.
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’d include it to begin a few f/u sessions, if she felt like these were particularly helpful in the past. Her fear levels are so high (actually refusing to attempt to pick up an object from the floor) that I’d be hesitant to throw her into the ring of pure active focus right off the bat. The article shows good improvement in FABQ scores after manual tx to TS, so I don’t see a particular reason not to unless she demonstrates any yellow/ red flags not listed here.
Hey Matt, nice job here.
1. Based on the subjective information presented above what are your top three differential diagnoses? (Ranking order)
– Trochanteric brusitis
– L4/5 radic
2. Based on the objective information presented above what is your top clinical diagnosis and why? Does it follow a clinical pattern?
– It sounds like an L4/5 radic with concurrent ipsilateral glute tendinopathy/ insertional bursitis. L4/5 radic could be playing a role in the firing of glute tissue. Her LS and buttock was recreated with LS extension/ Quadrants and CPA to L4/5… painful laying on ipsilateral trochanter, poor use of hip stabilizing glutes with SLS, lunge, and clamshell recreating hip pain.
3. Is there any information you would have asked during the subjective examination or
collected during the objective examination?
– More neuro screening.. reflexes, SLR, SLR + SIJ compression
– More info on function testing… was she dumping into LS lordosis, since you noted she even stands in anterior pelvic tilt?
– Aggs/ eases specific to each region… low back, buttock, anterolateral hip, groin.
– With more information, she may fit into the CPR for successful lumbar stabilization tx
4. What would have been your exercise prescription and educational interventions for day one?
– Education: dial down her exercise moves to the ones she can handle without form exception or sx recreation, for now.
– Exercises: substitute the exercises removed with ones that will build where she needs (DLS with ER resistance if painfree, “Captain Morgan” SLS iso ER at a wall, etc)
– Manual: consider a S/L lower lumbar segmental flexion technique for mobility and pain relief
Great article. I was reading bits of it since Monday, but had to let some parts simmer in my mind to try and let it all come together with my current knowledge.
I really appreciate the continuum model for how it lays out the known stages tendinopathy, which are both unique, overlapping, and ambiguous. Effective treatment relies on my interpretation of where the patient is presenting on the continuum. The model presents at least a map of what to expect so that I can tailor my treatment appropriately.
Pain is big in the model, and it’s essentially one of 2 items we’re really interested in (pain + function) in terms of rehab strategies. It’s my job to determine the patient’s presentation and give an appropriate treatment: reactive (address loading tolerance, aka function) <<or>> reactive-on-degenerative (address pain).
I had a 56yo active male who was having Achilles pain when he walks in flip flops (this was LA, so he wore these 100% of the time) and when he rows a boat for recreational sport (5x/week). His pain began 4mos ago insidiously, worsening to this point with additional apparent girth increase to the entire tendon. He’s noticed that while he can no longer tolerate rowing the boat d/t pain, and he can no longer walk normally or perform a SL heel raise on that side. He landed on the reactive-on-degenerative region, and we had to be really particular with his treatment to get him back to such a high level. We included…
– SLS with uniplanar >> multiplanar reaches
– SL RDL
– Standing BAPS
– DL tilt board balance and slow taps >> SL balance
– side step-downs (for eccentric DF)
My treatment was prescribed with his pain severity and irritability in mind and originally emphasized improvement of proprioceptive and mechanoreceptor response with the gradual progression to load tolerance and compound movements. (Great success!)
I can say that I had a much more superficial understanding of the proposed continuum wherein it made sense to me that a patient with this pathology will teeter between full function<>pain<>pain and functional loss. This article improved my depth of understanding, which can aide in my education to a patient, and it reminded me the other half of the spectrum leading to reactive-on-degenerative stages. Cam, this has been a big help and will aide in my identification of where a patient is presenting on the spectrum and which direction they are headed.
My opinion has some serious personal bias since I was the pin-cushion for someone practicing for their DN certification levels 1 and 2.
With a PEDro score of 9/10 I can appreciate the results of this review – and it’s not enough for me to use this as a first or second line of treatment for most PHP folks. I can tell you that the foot is serious in the amount of pain DN provoked, and I can’t imagine how intense that might get if I’d had an irritable pathology lurking down there. I might consider it for low-irritable, low severity folks who’ve had chronic pain, but it’d be after I’d demonstrated marginal<>no gains from less invasive techniques that are also research supported.
I appreciate that this review demonstrates improvement in first-step pain compared to sham treatment, but there have been studies that demonstrated positive benefit from alternative strategies including the study posted just before that demonstrates the improvement in foot function with a simple, progressive exercise protocol.
It’s in my toolbox… but I’m leaving it there for the tough jobs.
My immediate takeaway is the obvious outcome trend: while the pathology typically dictates a pain >> stiffness >> recovery progression, patients’ pain recovered last (6-9mos) whereas their mobility, strength, and DASH scores improved by the end of the treatment duration (3mos).
I really appreciated the thought progression that was obviously patient centered and very simply founded on perceived patient sx irritability. I mean, the techniques ranged from Gr1-4 in neutral, at midrange, and at endrange. Be as specific as possible, as tolerably as possible. It’s a good exhibition of maintaining a logical clinical decision tree that is based on the person in front of you. The pathology is going to take its course, and it’s my job to choose the techniques that make sense.
I appreciate the post, Kyle
I agree with you guys. Jeff, you’re right that the treatment should be individualized, but what I like most about this report is how vague the patient demographic was (e.g, ~50% pes planus / ~50% not, sx duration 2-84mos). Given the small sample size n=15, there was still a strong improvement in all 3 primary outcome measures with a strong p value a=0.001. This suggests to me that, while every patient needs an individual approach, I can respect the pathology at hand and recognize the general concept of appreciable early unloading to the anatomy.
I don’t have much experience with TCFOs, but a quick Google search suggests to me that they might run between $100-$300 (maybe you guys can suggest otherwise). I might opt to use leukotape arch support, as the study suggests benefit from artificial support for just 2 weeks… (though they admit a longer duration should be studied). I’ve had anecdotal success with this technique, the primary goal to conceptually unload the tissue along the medial arch.
I’d like to know more about the patients used in the study since 13/15 were female. Does gender specific shoe wear act as a predisposing factor? What were their BMIs?
Casey, I love 2 things about your article: 1) The combined concepts used in the study by placing the PF tissue on stretch while applying a high tensile load through a heel raise. 2) That it all goes back to the anatomy. “The plantar fascia is made up of collagen type 1 fibers (Stecco et al., 2013). It appears that this type of collagen responds to high-load through increased collagen synthesis (Langberg et al., 2007). As patients with plantar fasciitis show degenerative changes at the plantar fasciaenthesis (Jarde et al., 2003; Lemont et al., 2003), increased collagen synthesis may help normalize tendon structure and improve patient outcomes.” If we’re specific with what we’re treating, we can apply concepts to be more effective at tissue modification to reach our goals.
My takeaways are only limited to the context of folks with chronic pain, as this was an inclusion criteria for the study.
1.Based on the subjective findings, what are your immediate differentials? Do you ask any more probing questions?
– Supraspinatus impingement, partial RTC tear, supraclavicular origin (1st rib and scalenes have familiar referral patterns)
– If scalene or 1st rib were on my DD list, I’d be interested in some questions oriented to that including a report on his breathing even if he doesn’t outright mention it.
– I’d be interested if he felt there was a particular day or event when he began noticing his pain. Insidious onset is helpful to get a sense that it probably didn’t happen after a fall from a crossfit bar, but maybe it became noticeable after his 200th rep of shoulder abductions during a training session (or actually training for the police force).
– I’d also be interested in his typical exercise routine.
2. Based on the objective findings, are there any other tests that you would have performed?
– AC jt mobility, 1st rib mobility, length/ flexibility of pec minor and scalenes ipsilaterally.
– Special test to determine long head of biceps involvement for pain origin.
– OP into CS mobility to truly clear?
– He has difficulty with OHP and lifting objects out to the side – how’s his Inf glide of the GHJ?
– How’d his scapular motion look during shoulder AROM?
3.What is your primary hypothesis?
– sounds like a case of arnold schwarzenegger subacromial impingement
4.Do you agree with the order to have the “functional testing” after the rest of the exam? Would you have done this day 1?
– I love that you included it, and I think performing this at the end is smart. As stated prior, irritability depending this can be a great way to really observe the problem in action without confounding a specific, sterile objective exam piece later on since you’ve already gathered them. I also think this is an important piece to day-1 with this gent, since he’s a 27yo police officer, cross fitter, gun shooter, and heavy lifter. It sounds like he has high expectations of himself physically, and you examined what he really values. This shows that you’re not going to just tell him to stop lifting – rather you’re actually interested in seeing how you can get him back to where he feels like he should be.
5.What interventions would you have performed on the first day? More/less/different MT? Different exercises? Let me know your thoughts.
– Sounds like a great opportunity for a TSpine manip
– This wouldn’t be my first go-to, but KT tape could be a good tool to include as an educational piece and add proprioception to this 27o he-man demonstrating your postural points.
– I’ve found that a gentle inferior traction in neutral to the GHJ provides significant relief to folk who have a hot supraspinatus tendon.
– Simply providing a few designed sets of AAROM to the affected arm’s scapula during AROM GH movement in the affected planes has served me well in 1) providing pt understanding of what kinds of muscle groups I’m asking them to use and 2) provide a NMR benefit to actually using them.
– I like that you gave him a few home-run hitters that attack the low hanging fruit in your exam. You immediately showed him your value as a clinician and can later work on the bigger piece – lifting heavy weights again without pathologic limitation.