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Interesting case Scott. Thanks for posting.
1.
He doesn’t really fit the CPR for manipulation. However, as you stated, he noted improvement following manipulation. I don’t think I would have proceeded with a lumbar manipulation since your initial treatment was working. He was receiving Chiro care before and is in PT now because he possibly wants something different. (Do you think that statement is true?) Having said that, I probably would have manipulated his thoracic spine to help reduce neural irritability (in a slight SLR as we talked about this weekend) prior to working on additional direct techniques.2.
Like August, I would have assess thoracic mobility. I would like to say I would have also assessed anterior hip articular mobility. I know you said you assessed myotomes that were negative. Did you also check INV strength in addition to DF? I would have also assessed hip FABER position.3.
If his foot drop was worsening, I would be concerned. Additionally, if myotomal weakness arose and if N&T was reported to be worse and/or the duration was increased. Even if the physician was not informed, I would not have referred out but would have just communicated it in my evaluation findings and plan if signs/symptoms worsened.4.
It would make sense to me that this may have been an unprovoked symptom with running since it had not previously been performed prior to starting PT. It might be worth mobilizing his hip into extension and then getting him back onto treadmill (as you have shown improvement with lumbar extension). I would be curious to see if mobilizing the his was more or less beneficial.5.
He was in the military and works out 7 days/wk. Do you think we would be able to get him to modify his activities/routine? We could maybe discuss decreasing weight at this moment but not sure if that would work for this particular patient. Could also talk about potentially decreasing days he works out to maybe 4/7 or something to allow more healing time. Just a thought.6.
Like August, I can’t say I’ve specifically done this. But I have seen several posters at conferences addressing cervical mobility (with manipulation) followed by neurodynamic mobilizations for patients with radicualar low back pain. It can certainly be beneficial sometimes to treat away from the irritable segment but the pt would certainly need to be educated on why it may be beneficial; particularly if you want to get buy it. For this guy in particular, it could be easy to get buy in since he likes to bike. You could take a picture of him on the bike with his phone and educate him on his cervical/lumbar positioning and the effects it can have on his overall posture or low back pain.In regards to cadence and shoe wear in return to run phase. Would you want the pt to run in less of a minimalist shoe (zero drop)? With this shoe, he would likely adopt a forefoot to midfoot strike pattern – increasing the stress at the achilles complex. Therefore, it makes sense that a higher drop shoe would promote heel strike and decreased stress.
Same goes for retraining cadence. Would you potentially want their cadance to be decreased (depending on their “norm” obviously) to lower the potential for a forefoot/midfoot strike pattern, subsequently decreasing stress through the achilles complex?
I’m curious because I see very few of these patients in clinic. Just throwing out some thoughts I had. Let me know your thoughts.
Phase III:
Continue activities and exercises from phase II but begin to increase direct strength of achilles complex to improve tolerance to load.
Progress from isometrics to concentrics. If necessary, start in open chain with a theraband or power band but progress to closed chain. Start with a tolerable load. Could be using a total gym or leg press with decreased weight. The research shows that he should avoid tendon compression; therefore, avoid dorsiflexed position during these exercises to start (will progress to this position in phase IV). Perform the exercises in mid range to reduce stress and compressive load distally. Some discomfort with these exercise are expected but increased pain following exercises is not. Higher repetitions of these exercises are what have been shown to be effective in the literature. Allow adequate rest days in between tissue loading days as there is a loss of collagen production for 24-36 hours post exercise. This means the pt should allow at least 1-2 days between exercises.
Phase IV
Phase 4 is a progression of phase III; progressing the acceptable load on the achilles. Exercises from phase III can now be progressed from mid range to full range and from concentrics to eccentrics (or heavy slow resistance as both have been shown to be equally effective in the literature).
Example of gradual heavy slow resistance could be:
-Heel rises with knee bent on calf raise/leg press machine, heel raises with knee straight on leg press machine, and heel rises with straight knee standing on a disc weight with the forefoot (to allow some DF increasing load and tension) with a barbell on shoulders.
-These exercises would be performed 3x/wk to allow for adequate rest time on achilles
-These would be progressed weekly by decreasing repetitions and increasing weight.
ie (from Beyer et al):
3 times, 15-repetition maximum (15RM), in week 1
3 times, 12RM, in weeks 2 to 3
4 times, 10RM, in weeks 4 to 5
4 times, 8RM, in weeks 6 to 8
4 times, 6RM, in weeks 9 to 12The Alfredson study study requires a very high number of repetitions and therefore can be very painful due the exercises being unilateral. The heavy slow resistance prescription allows for the patient to perform less repetitions and increase wt to increase the vigor; likely increasing the compliance of performing the exercises.
Strengthening the achilles appropriately to gradually increase its load tolerance can take several months and this should be made clear to the patient. Following Phases III and IV the patient’s achilles should be strong enough to begin a return to run program in phase V.
Thanks, will do. I think it makes sense to have the whole medical team on the same page to provide the best care to the patient. So we should at least know the differences in our language to prevent miscommunications.
Thanks for the information, Kyle. Perhaps, I will be using radiculopathy more often in my assessments instead of radiculitis. Maybe the assessment portion of my exams will be sound more like “radiculopathy with/without signs of nerve root compression including myotomal weakness/sensation loss/diminished reflexes”.
Does that sound better than “L5 radiculitis”?
I like how much emphasis was put on the patient’s subjective history at the beginning of this article. I feel this is an area that we excel in as physical therapists (more so than docs due to the duration of time we can spend with our patient) and a thorough history can direct and expedite our objective exam.
One thing from the History portion of this article I found interesting was that it talks about a patient reporting pain in the hip while lying on left side is likely indicative of trochantaric bursitis. For myself, I generally think of the that pain as a referral from a lumbar facet (thinking about the patient being side bent), and then look toward a glute tendinopathy. I feel like the research generally supports the lack of true trochanteric bursitis cases. Also, from the History portion, the article didn’t mention any correlation between L1-2 and groin pain. I have found that on several occasions.
I also use the Laslet cluster to rule out SIJ. The article did mention 2 of the 6 tests to rule in SIJ but did not mention the rest. This could be to expedite the exam. I thought it was interesting there was no mention as using the pubic percussion test for femoral neck stress fracture, especially based on its sensitivity.
For lumbar pathologies the article didn’t mention radiculitis vs. a true radiculopathy. Also, didn’t mention annular tears or facet dysfunction. It could just be a terminology thing and it was good to see the terms that MDs primarily use and are familiar with. I feel like my communication with MDs regarding these pathologies may need to change a little bit.
In regards to terminology, the article did not mention motor control dysfunction which is similar to Scott’s case this past weekend for the hip. Also a common disfunction in younger female population with low back pain. There may be a better way to communicate these findings to a doc if these are terms they do not use.
Overall, I thought the article was good. I liked how they really drive home that usually back and hip pathologies are not in isolation and typically both display pathologies that need to be treated together to obtain full resolution of symptoms. I feel that, as physical therapists, we experts at identifying hip and lumbar pathologies and their correlation. Its nice to see that MDs are looking at these things as well. I always like to give patients a pie chart analogy to explain findings (“70% hip, 30% lumbar”) so they know why I’m treating both.
That is pretty cool, Scott. It certainly makes things easier if the patient can give you an example to build off of. It kind of speaks to what Eric has been saying about asking the patient to reflect and throwing in little nuggets (or strips if you prefer) along the way for them to think about.
To help a patient understand central sensitization it can be beneficial to help them understand with a peripheral sensitization analogy. David Butler talked about using sunburn as an analogy.
A sunburn can be a great way to do that, as most people have experienced a severe sunburn at some point in their life. Have them reflect on what it felt like. Ask them what it felt like to get a warm shower or even wear clothing over the affected area. Explain that this is due to sensitized nerve ending in the skin; becoming sensitive to the heat and/or pressure.
You can then ask the patient what it felt like after they were in the shower for awhile (the nervous system settles down and doesn’t hurt as much).
This can help reduce fear of movement. Just as the nervous system settles down while in the shower, it can settle down with continued movement. You aren’t fearful of the pain while in the shower, why are you fearful of the pain when walking, bending, squatting or whatever. And this conversation can only continue from there.
Thoughts on using this analogy?
1. I have yet to treat a patient with TOS (on clinic rotations or since practicing). But overall, I think your assessment of structures and body regions was quite complete. Only thing to potentially add would palpation along neurodynamic pathway soft tissue; but I don’t think that would have changed what you knew already.
2. I used to give them regularly at evaluation until our 3rd weekend when we were taught that, that might not be the best idea. Luckily in that time time frame all those patient’s came back to the clinic without a very angry nerve. But since weekend 3, I have not given them day one. I may perform them day one and assess asterisks but now I do not give them as a HEP on day one.
When describing neural mobilizations, I typically will give some spiel about the nervous tissues needing to move through fascia just as arteries veins and other tissues need to. And essentially what I am doing is teaching the nerve how to move again by slacking one side and tensioning the other; and vise versa. However, I like Erik’s analogy.3. A chameleon’s tongue can be more than twice the length of its body
4. I struggle a lot with this as well. In addition to what Scott mentioned, I have learned not to bail on a treatment if it doesn’t help the first time. If, based on your subjective/objective exam and clinical reasoning, treatment of the first rib is indicated, then perform a technique. If you reassess and do not note a significant improvement, it may be worth performing another bout or at least revisiting the intervention.
5.As Erik mentioned, certainly try to modify work. However, in this case it is emotional stressors. It is important to get the patient to understand how emotional stress can influence their pain first.
I have had one pt where emotional stress at work as a CNA was exacerbating her pain. I don’t remember how I initiated the conversation but we began talking about the parts of her job that seemed to increase her stress and anxiety. We then talked about ways to modify/avoid these stressors. I also initiated a conversation about what she enjoyed about her job. She talked about interacting/communicating with patients, talking to family members, and the appreciation patients had for her after getting “cleaned up”. She mentioned to me that she had never really thought about what she liked about her job and that she felt she might appreciate these moments more now during her day. So far it seems like it was a win, but time will tell. It was certainly an uncomfortable conversation for me as I was stepping into the unknown.Sorry to hear that August. I hope all is well. This article is a nice review of all the balance measures we use. I just started seeing medicare recently and have just started using these outcome measures/assessments. I have been trying to refresh myself on cutoff scores for these tests. Thanks.
That was an interesting statement he made, August. I almost feel like that is just a way of him validating non-specific techniques for himself; It is easier to do, therefore, I feel more comfortable as a clinician. Is it truly better to assess in a no-specific way because you feel more comfortable?
For an analogy: I like chicken alfredo. The kind out of a jar is much easier and I am more comfortable making it (obviously). It taste fine but no where near homemade alfredo that takes much longer and is much easier to make a mistake while preparing.
So in regards to the assessment. I may feel more comfortable because I have to “feel” for less things when assessing in a non-specific manor. But to state that I am providing better care because I am more comfortable is possibly a bold statement.
Thoughts?
I remember reading this article this summer and being both encouraged and discouraged.
The author makes a lot of good points. And I feel most of the manual therapy community has shifted in the direction he mentions. Most therapist now understand that manual therapy is creating a neurophysiologic cascade of events rather than strictly increasing mobility at a segment.
I think the research has demonstrated well that we can identify hypomobilities but might not be as good at identifying hypermobilities. Like the article mentioned, we definitely can’t divide 1mm of movement into a 5-7 degree scale.
The article questions the necessity of specificity. In the third true/false question in the article the author makes the point that one can pick any level randomly and have the same benefit as a specifically picked segment. As this is somewhat true and he backs up his argument with studies, most studies show some superiority of specific technique over general technique. The differences are generally not found to be significant and are rather small, but are slightly better none the less. So, perhaps, it is in our best interest for the patient to be the best we can be and continue to attempt to be as specific as we can with out techniques.
I really liked this statement by Jim Meadows in the commentary section as well. Helping show that clinicians play a role in research and shaping the direction of PT practice.
“That you are predicting that your article will not make it into a
peer reviewed journal is, I think, an appalling statement about the
state of the clinician’s place in a world where researchers (who
are not always the innovators and bright sparks that you would
like leading) rule.”I agree, Scott, that is can lead to a reliance on passive techniques. But as you mentioned it can easily be communicated to the patient through assess, treat, reassess.
For example, I am treating a pt for lateral epicondylagia. We had made improvements and he was painfree for about a week before having a setback. He came in on day and said he wanted to have ultrasound he had heard and read that it is really helpful. I explained to him the current literature on US and that previous treatments that we performed were useful. However, he was insistent and felt very strongly it would help. So, I performed US for the first time in my short career on my patient’s elbow (definitely not my proudest moment so far)…Anyways, I made sure to assess prior to treatment and reassess afterwards. No improvements were made in asterisks and he agreed that it was not a worthwhile treatment; since I had previously shown improvements with manual and exercise techniques.
Interesting point, August. If that is part of the plan, I think it is great. However, I feel like this isn’t reaching many patients. Their webpage says they are “improving health and social care through evidence-based guidance”. I feel this is primarily for the providers. I did a quick “google news” search of the guidelines and only 3 articles were present. All 3 were for physiotheraist, non were news articles published in the general public’s reading material.
I think if the NIH published something like this and then a large media source wrote a few articles with the input of practitioners on pain neuroscience and healing; that potentially it could help change the publics view of the horrific disc and lower cost. But only if the public saw it. If you did a quick search of disc herniation in the google “news” tab, you would get a thousand articles of Gronk’s disc herniation, surgery, and time to return to football; only increasing the fear of people when they have an image that shows they have a disc herniation.
The talk of slings reminded me of a case study I read in one of John Gibbon’s books. He talked about a runner he was seeing for shoulder pain. The only time the pt had shoulder pain was about 4 miles into her run. The pain lasted for a little while after the run but then would resolve until the next run. During his exam, he checked the glute activation of the pt in prone. He noted decreased/delayed glute max activation of the contralateral side. After a couple weeks of glute activation exercises and cuing the pt was able to run painfree.
So, was it because the ipsilateral lat was overactive trying to compensate for the deficient glute leading to shoulder dysfunction? It would make sense that the lat was pulling the UE into greater shoulder extension during arm swing potentially leading to a repetitive impingement phase with each arm swing.
Has anyone treated or seen something similar to this, where treating a body region most would typically think was unrelated to resolve a patient’s complaint?
I can recall treating a R handed pt with R LBP that occurred after several sets of a tennis match and occurred during his backhand swing. After getting a subjective hx, the pt reported previously having a RCR on the L shoulder. After assessing L shoulder ROM, he continued to significantly lack IR ROM. Hip IR was symmetrical and not limited. So was his lumbar spine possibly rotating more during his backhand swing because of the shoulder deficiency leading to facet dysfunction? Well, after treating his shoulder to improve IR ROM and showing him self mobilizations he could perform prior to his matches, his back pain resolved.
I find these cases interesting and difficult for myself to pick up on early on in a pt’s treatment. Has anyone else had cases like this in nature?