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Hi Katie,
I see what you mean about feeling conflicted after giving the 2007 article a quick scan. I interpret the recent commentary by Chad Cook et al as an attempt to swing the pendulum back the other way. Perhaps their thought process has evolved over the last 10 years and they’ve realized we are putting too much weight on red flags, rather than using that information more discerningly to guide decision-making.
I like the watchful waiting quote as well. It makes sense to me that a watchful waiting approach can in some ways improve clinical reasoning skills and patient/therapist communication naturally by the monitoring and interpreting of changes in symptoms.Thanks for the article, Aaron –
This is interesting because it touches on the self doubt one may have when trying to decide if a “red flag” is worthy of a referral. Their explanation of how red flags were initially used as a screening tool or at least proposed as screening tools but morphed into part of clinical diagnosis/management is persuasive in that I found myself agreeing with the rest of their commentary. If many of these screening tools are very poor at ruling out a serious pathology, then it makes sense to weigh them less heavily in clinical decision making. In other words, I’m likely to be more cautious in interpreting red flags after reading this article. Or a better way to state this may be – Red flags should be considered as a small piece of the overall clinical picture, and thus guide decision-making, but not dictate decision making(ie. this patient needs an x-ray right away because of this one red flag).Hey Tyler,
Thanks for posting-
1. I probably handle the lack of available evidence the same way you did – expand my search to tendon injury in different areas of the body, eg. Achilles and try to discern what’s applicable to my particular patient’s injury.
2. Regarding the hamstring stretching. My first step would be to have her demonstrate how she performs the relieving stretch. It’s possible she may be getting relief from some other aspect of the position besides actual hamstring stretching, possibly posterior pelvic tilting?. After checking that out, I would have the conversation about tendon injuries not typically preferring stretching. I would likely encourage her to keep it low intensity if she must stretch.
3. I think I may start this patient on isometrics in the first session, knowing that we may quickly move on to the next phase. It may help with reducing the pain that comes with sitting.Ditto previous comments on the helpfulness of the chart suggesting alternative language.
Another point I liked -“When we are physically and emotionally low, we not only hurt more easily, we also seek information that supports our vulnerabilities.” This point is helpful in considering how patients may interpret and hear part of what we are saying, or grab on to the negative connotation of a seemingly neutral word or phrase, making it all the more important to consistently work on improving our communication style.Thanks for posting this, Katie. It’s a very good, short read.
I think this helped me rethink the implication of the “wear and tear” phrase. I often use “wear and tear” when I cannot come up with a better description for a degenerative joint issue. I say “wear and tear” thinking that it sounds very non-threatening by comparison to other lingo patients have heard. While this might be true, I haven’t really thought about the way that might make patients think the problem needs a technical fix. I will definitely keep this in mind. Thanks for passing it along.I did find this to be a helpful review of tendon and ligament anatomy and physical properties.
I saw a new patient today with achilles tendinopathy and retrocalcaneal bursitis, 50 yo female, works in housekeeping. She was placed in a walking boot for 6 weeks and then issued a heel lift and a Rx for PT 2 days ago. She has been limping around for 2 days, loading her lateral column and avoiding dorsiflexion. I can’t think of the rationale for the 6 weeks in a boot rather than PT during that time period.The author states that the female gender is an intrinsic factor associated with tendon degradation rather than adaptation. I can’t think of any rationale behind this. Can anyone enlighten me?
Hi Katie
I’m finding it challenging to make sense of his symptoms.
When you say ULTT reproduced symptoms does that mean it was the same quality – dull and achey?
Were CPA’s or UPA’s painful at any level or just hypomobile?
Did you happen to support his UE’s and recheck cervical AROM? or adjust his posture and recheck cervical AROM?After finishing Katie’s article, my oversimplified take away from the author’s conclusions is: Outcomes are no different if you pragmatically utilize thrust or non-thrust manipulations in this patient population. Did anyone come away with a different message?
Thanks for posting this article – entrapment or extrapment of a meniscoid is not usually on my mind when trying to determine the source of a patient’s cervical pain. Given that Katie’s patient responded well to distraction, then manual traction as a component of treatment makes sense. Considering that multiple directions/planes of movement provoked symptoms, I can see opting for mobilization over manipulation.
One of the patient’s goals was to learn some stretches to help the neck. With a patient like this, with multiple flexion and extension biased provocation of symptoms, I find it difficult to decide what type of neck stretches may be beneficial. I probably wouldn’t assign stretching for HEP initially. Does anyone else have difficulty with this?Hi Katie,
Thanks for posting.
I think you address the preconceived notion of needing the “crack” by educating/explaining that manual techniques, including but not limited to manipulation, will be part of his treatment plan. Explaining that manipulation may play a (small) role in his treatment should make him feel that his preferences are being listened to but also help him understand that PT is more than getting your neck cracked.
I think I have a bias that makes me think twice before providing a treatment that a patient has specifically asked for. I think it’s because I want to make sure I feel it’s the right treatment at that moment. So, I try not to let their request or preference weigh as heavily on my decision. I’m not sure this a good thing though. I guess you could argue that I risk losing some patient buy-in if I’m too rigid in my decision making.I have a hard time picturing how to stress the specific tissues to gain helpful information when the patient is highly irritable. I tried using the ULTT as a gauge of irritability with this type of patient, but I was not able to figure out if the irritation of the nervous system was stemming from interscalene, or clavicle/rib, or subpectoral space. Has anyone else had success with this type of presentation?
Hey Tyler,
Sorry for the delayed response. I have way more questions than answers. Did the proximal and distal symptoms have the same onset? Do you think the lower cervical, CT junction could be the primary issue? With an elevated rib or TOS contribution? In sitting, you could assess cervical rotation lateral flexion.
While performing ULTT A in supine, were you able to differentiate the impact of cervical positioning or contra UE?