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I feel that protocols are designed based on tissue healing of the repaired/removed tissue. So we should definitely respect the guidelines that the protocol lays out in those regards but also like Scott mentioned, use our functioning brain.
There was an article in May BJSM that showed post op ACL patients had a 51% reduced risk of re-injury for every month return to sport was delayed (up to 9 months). It just demonstrates that just because the protocol says the patient can return to sport, we need to make sure they have met return to sport criteria such as single leg hop symmetry, symmetrical quad strength, quad/ham ration, etc. Additionally, it demonstrates the benefits of delayed return to sport if the patient is willingly to delay return to sport.
Also, we need to think about progression of exercises in regards to protocol. Mike Reinold talks about progressing throwers to return to sport. If they have not performed 2 handed plyometrics, you can’t perform single hand plyometrics; and if you have not performed single hand plyometrics, you can’t start throwing. So just because a protocol says the patient can perform x,y,z we need to make sure they are appropriate and safe to perform that.
I feel like I just rambled on about nothing…But, in regards to the article, I thought it was great of the PT to individualize the patients care. I feel that some, if not the majority, of the public still view physical therapy as the profession that takes patients through “the preprinted sheets of exercises”. I hope this article helps to change the public’s view of PT in that regard.
Brett showed me a way to perform the supine technique from the ipsilateral side for those patients with a larger BMI and/or chest circumference. I have also had some success with using a keltenborn wedge in supine for larger patients that were unable to tolerate prone or assume prone due to excessive soft tissue. I don’t like that technique as much because I’m unable to make those small movements with my hand to increase/build the barrier.
I, like everyone else liked how direct and concise the guidelines were. I think it is important that they preface the guidelines, stating that they are just that, guidelines. Some patients require more of a multimodal approach, like Nick mentioned. Some patients come in with preconceived notions about the effectiveness of specific treatments. As of recent, much of the research talks about the effects patient beliefs can have on patient outcomes. I have had a couple patients tell me about how traction helped their relative and that they feel that is what they need. I’ll always discuss the additional treatments that will supplement their care, but I do make some form of traction part of their care (manual (usually) or mechanical) if they strongly feel it will help.
I have tried to make it part of my practice asking patient’s their goals for therapy and what they feel will help. Some patients simply say “I don’t know” but some have preconceived opinions about certain therapies that should at least be addressed with the patient. Even if you end up not performing the treatment they mentioned, it should at least be discussed to help them understand why it will not be performed.
Thought on where patient beliefs fit into these guidelines?
I rarely, if ever, address or cue core activation with scapular shoulder exercises. It makes complete sense as we know movement pattern are more complex than just picking a exercise with high EMG activity for the muscle we want to target. We don’t function in isolation as this article demonstrates. I think I will be cueing core activation with shoulder exercises now. Good find Scott.
I’ve attached an article regarding EMG changes of scap muscles in patients with acute shoulder pain. The other article discusses kinematic changes in scap and GH movement in those with shoulder pain.
As far as palpating the TA goes, I’m pretty sure we all agree we cannot confidently palpate the TA without IO. Like August said, looking for core contraction without RA is typically appropriate I think.
Good point Scott. I have had several patients I have discharged with still some a few functional limitations. When discussing discharge with them, the conclusion was made that they could manage their symptoms on their own for awhile based on the treatment strategies I had given them. This is definitely the patient you are referring too. It would be great to see this patient back in the clinic in 6 months to see where they stand with their ADL function in regards to their pain.
August, I also have no experience with functional screening tools but was curious as to everyones thoughts on implementing these as a screening tool. I agree that only using a functional movement screen could limit our clinical reasoning and judgement like you mentioned.
Interesting case Nic.
What other screening tools/tests would you use for this pt presentation?
I think doing a neurodynamic screen would be appropriate for her. We discussed in the UE weekend about the potential radial nerve involvement in lateral elbow. Anecdotally I have seen this be the case for a few patients I have had with lateral elbow pain. I also think it is appropriate since she reported N&T. Was the N&T in the entire hand or did it fit a neural distribution. Were you able to reproduce her N&T in the clinic? Do you think it was more from the sustained cervical position of sustained shoulder/elbow position? Or potentially form the sustained pressure over gyon’s canal? I think I may have performed sustained cervical positions with OP since it takes 30 minutes to bring on the N&T (although it sounds like you did this). I think I may have performed PAs in the cervical and thoracic spine to look for symptoms reproduction depending on time I had.What other objective measures would you test/did I leave out?
I would have checked grip and pinch strength but you went back and got that 2nd visit.What Tx strategies have you used for lateral epicondylalgia or TFCC dysfunction?
I have yet to see a TFCC lesion in my lengthy career but have seen several lateral epicondylagia patients. I have used radial ulnar nerve mobilizations. I think in your patients case that it will be very important to address wrist mobility as restrictions here may be leading to increased tissue stress at the lateral epicondyle. I have also found eccentric loading and thoracic manipulations be useful.How do you manage chronic pain and overuse type injuries in patients who do not have the option to take rest/time off work duties?
I think what you did is appropriate. Finding a way to either modify their work to decrease tissue stress or providing them with ways to modify their body to reduce sx (in this case you used taping techniques).Have you utilized taping techniques for these or other body regions?
I have used taping for a few patients with knee pain for patellar fat pad unloading. Also for 2 patients providing scapular position awareness.Was it beneficial?
My success with these techniques have been about 50/50. That may be because I’m not proficient at these techniques but I feel 50% success with taping is not too bad. What have other people found as far as success with taping?Should shoulder strength/conditioning be included in progression of tx program?
I know there are several studies (not RTCs or case control studies) that have shown relief of lateral elbow symptoms with only periscapular and shoulder strengthening exercises. If I have found weakness in my patient’s with lateral elbow pain, I implement scapular strengthening exercises. Whether or not that is the actual reason for relief of symptoms, I’m unsure because of all the other manual and exercise being performed. I’m not sure of any studies using shoulder and scap strengthening for wrist pain but I think it is appropriate if deficiencies are found.I like the idea of having bi-annual or annual PT check-ups to discuss preventative care specific to their ADLs. I feel most discussion would be on work station ergonomics and preventing upper/lower crossed syndrome. Also, educating patient’s on postural awareness and the increased potential for injury with poor posture.
I think Myra’s comparison with dental checkups every 6 months is a good comparison. Just as they see less cavities with checkups. I think we would see a decrease in injuries and pain. Particularly shoulder, neck, back and knee pain based on the effects we know posture and mechanics have on these body regions.
With the talk of annual/bi-annual check ups, do you guys feel the FMS and SFMA screening tools would be beneficial to perform during these check ups?
Several blogs I follow in addition to the ones mentioned today are:
“Rayner and Smale”: If I had to pick one I have found the most valuable, it would be this one. Especially for a new clinician. A good blog that discusses current topics, rehab pearls and clinical reasoning. They do a good job of explaining topics using current literature to support their comments. Most recent blog post was on neurodynamics after taking a Michael Shacklock course. Definitely worth checking out.
“The Manual Therapist”: Erson Religioso usually posts interesting topics related to PT. Also, has has youtube videos with skills and manual interventions he has found useful. He really promotes his products like the edge tool, mobility bands, suspension trainer, and his courses he has created with Mike Reinold. But overall, worth looking at if you have time.
“The gait guys”: I haven’t read their stuff for quite awhile but they usually post interesting cases involving the LEs, usually runners. Some things they mention can be a bit questionable, but overall, I feel it is worth looking at if you have time. They also produce podcasts.
“Shift movement science”: Dave Tilley works with Mike Reinold at Champion PT and specializes in rehabing and preventing injuries in young gymnasts. I don’t really see any gymnasts but some of the topics he talks about can easily be considered with general ortho patients and I find it interesting.
Thanks for the case Brett.
In regards to the discussion questions you posed:
I think I may have screen the patient’s shoulders. Just as we often find relevant hip asymmetries with LBP patients, I feel we can find relevant shoulder asymmetries when treating cervical pain. I also may have screened his upper quarter neurodynamic mobility, just to assess the involvement of his neural/dural tissue.I have found utilizing objective asterisks to be very useful for both myself and the patient. Initially I was using 5-6 asterisks I would check every visit but I have learned it is better to pick 2-3 that I want to check each visit. This helps me monitor progress and also helps the patient note improvement in their condition, which is potentially more beneficial.
I try to utilize DNF training and thoracic mobility intervetions with almost all cervical patients. As for choosing between t-spine manipulation vs mobilizations, I typically choose manipulation if there are no contraindications to the intervention and I can based on the patient’s body size. The literature shows t-spine manip to be slightly more beneficial that t-spine mobilization, so if possible, I choose manipulation.
As August mentioned his progression, mine is similar. Once they understand the chin tuck and nod and can maintain form, I progress to performing periscapular strengthening exercises while maintaining the chin tucked position (such as a low row to improve lower trap activation and additionally to promote thoracic extension). I have also used a mini theraball against a wall with the patient standing at a 45 degree angle and perform a nod against the ball (theoretically getting a greater unilateral contraction of the DNF).
I would like to know how other progress DNF activation exercises as well. I think I could improve on my progression.
Thanks AJ, glad I read that. That will be helpful for me because I feel like I ask every patient “do you feel your pain is limiting you at all throughout your daily life”. I will definitely be more cognizant of this when communicating with future patients.
Interesting article August. It will be interesting to see future research on this and when it starts popping up in other articles as an outcome measure as the FABQ has.
In my limited clinical experience I have only had a few patients that were truly fear avoidant. I have primarily used educational interventions thus far, and realized I am not that good at it yet. As of recent I have had a few low back patients I have been successful with. I used educational analogies using other joints as examples.
One in particular I have been using is Peter O’Sullivan’s wrist example. Explaining that if I made a fist all day trying to protect my wrist joint, bending and moving it would be painful (then I have them try it). Additionally, my ROM would decrease because my muscles are preventing it from achieving end range, leading to decreased joint mobility. The back is no different, just think of it as a bunch of little wrist joints. If you guard it by tightening your core with every movement, it might be a little uncomfortable just as the wrist is when you move it while maintaining a fist. It doesn’t mean something is being damaged, just that you muscles are trying to protect the spine and they don’t have to. Just as relaxing your fist made your wrist feel better and move better, so can your back…This has been somewhat successful for me for 2 patients in particular this past week. But I have to continue to work on my ability to educate patients that are fear avoidant.
In regards to graded graded exposure and graded activity, I have not used either in the clinic yet. I had a patient this week that indirectly reminded me of the importance of this and its effectiveness. She was involved in an MVA and verbalized to me that she is still terrified when driving her car. She told me that she has planned several 10 minute drives during her days to re-establish a sense of safety when driving. Just as she has created graded exposure goals for herself in regards to driving, we should to the same with patients who fear certain movements. If the pt fears vacuuming their house due to the pain it causes, we should set goals, as AJ has mentioned, to start with vacuuming their living room this week. Next week, vacuum the living room and bedroom…And so one. Like I said, I have not used this in the clinic yet but I will try to use them the way AJ has mentioned he has found beneficial.
I have tried using a similar strategy with that August mentioned when pertaining to OA, primarily the hip and knee. Another strategy that I use mainly for those LBP patients that are fixated on their bulged disc or stenosis that showed on on their MRI is: asking them if their pain is different throughout the day. The vast majority, with questioning, respond that their pain varies throughout the day. Whether that be better in the morning, mid day or evening…their pain varies. Let’s just say they say that their pain is better in the evening. I’ll ask them if they think their “stenosis” looks better or different when their pain is higher during the day. Then progress with some statement about how their variation in pain is based on the brain’s perceived threat throughout the day. If they question about the brain’s perceived threat, I’ll give a quick explanation of Adriaan Louw’s metaphor, the home security alarm.
Sometimes when you point out that their pain is variable throughout the day and their “radiographic diagnosis” does not very within the same 24 hours, they understand that their pain may not be directly be related to their said diagnosis.
There are several older articles looking at the effect patient centered goals have on outcomes. These studies were primarily done with neuro patients post CVA. Patient centered goals were defined as goals directly related to the patient’s values, expectations and expressed needs. Patients that were involved in goal setting demonstrated improved teamwork, motivation, and compliance. Ultimately leading to better outcomes. I think this emphasizes what Kyle mentioned about building an alliance with the patient to improve overall buy in.
Although these neuro studies are older and not orthopedic in nature, I think together they can potentially lead us to the observation that patients with chronic conditions may benefit greater from a more in depth goal setting process during their evaluation.
Thoughts?