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As with August, I feel that several of these biases may apply to me in my first year as a clinician. The category that stuck out to me the most was cognitive bias related to heuristic failure. I think the ones I have allowed myself to fall into include anchoring and premature closing. Retrospectively looking back, I think often times I see an intake form and/or hear a subjective history and think that it has to be a certain diagnosis. In times that the objective examination begins not to fit my primary diagnosis I become flustered in trying to re-direct my exam. Not coming up with the appropriate diagnoses has left my exam incomplete or fractured. I think that premature closer is another one that sometime clouds my judgement, I can think of one or two patients that I have thought they fit a certain diagnosis. When they are not responding to treatment as expected, I wish I would have gone back to re-examine different potential diagnoses.
What I took from this article and would like to implement in my practice is the solutions they provide in avoiding diagnostic errors; particularly acknowledging that the initial “working” diagnosis may not be the final diagnosis, accept what you do not know, and being open to both confirmatory and nonconfirmatory data. Trying to hedge diagnoses and treating with several different treatments may not be as effective as applying a primary diagnosis and not hesitating in re-examining and re-evaluating them if necessary.
1)Any other exam techniques you would have performed?
This has been mentioned previously, but again look at patellar glides more closely. Additionally, she subjectively reported performing stairs one at a time. Functional tests like a step-up or step-down may provide you with information on how she moves if this is an aggravating factor. She had moderate to severe irritability so maybe this and other functional tests, double limb squat, single limb stance, could be evaluated later one once she is not as irritable. Also, as Justin mentioned, I would have looked at a straight leg raise with resistance.
2)Any other treatment you would provide?
I would incorporate the external rotation component of the tibia at end range extension with a screw-home mechanism mobilization. As Justin mentioned, I like to perform physiological motion in open pack position following mobilization. If the patient was positive for neurodynamic testing and tender along the posterior hamstring, I may focus on soft tissue mobilization along this region and reassess knee extension with slump testing.
3)Does anyone have specific parameters they use for return to run/walk program?
I currently have a patient with medial tibial stress syndrome that I have been utilizing the graded running program described in the article I attached below. I have not had much experience with this but have been trying to incorporate some type of graded program with patients who want to return to running.
4)I have not used manipulation with this patient as of writing this. Articles describing the use of manipulation for patients with knee conditions usually describe the benefits stemming from increased quad and gluteal activation reducing PFPS or improving patients muscle activation following ACLR. How do you think this case varies from those presentations and how would you have you added lumbar intervention to treatments if at all?
This case differs in that the patient is somewhat older with a history of low back pain with a longer duration of symptoms (1 year versus no more than six months) and not as much PFPS but a meniscal pathology. I may continue to treat locally and with hip/lumbar strengthening. If there were no resolutions in symptoms, I may consider lumbar manipulation. Like Justin stated I utilize a thoracic spine directed manipulation due to positive slump testing. If this was beneficial I may move to the lumbar spine.
Discussion questions:
1. As you were, I would have been very curious with her mentioning congenital hip dislocation. Along the similar lines of Nic’s questions, I would have been interested in her activity level as a child and if her hip was some hindrance. It’s hard to speculate but I would imagine if she had dislocations or severe difficulty, she might not remember with what exactly, but that she did; more so during her teenage years than younger. Did this ever spark curiosity with her to look into the procedure she had or discuss this with family members? Also, I’m with August in regards to concerns for blood supply; she may be someone who would benefit from some education with regards to degeneration/ femoral head avascular necrosis.
2. It sounds like you performed everything necessary to confirm your primary and secondary diagnosis. Like Nic and August alluded to, functional tests may tell you more about how she moves which may guide treatment.
3. Like Nic mentioned, prescribing exercises that are specifically functional for her. With lower extremity strengthening did you include balance/proprioception exercises, I might include those as well.Article Questions:
1. I agree with Nic and Erik, the intervention group was generic. They mention that the “active physical therapy program may not adequately target and change physical impairment.” For a very hypomobile hip, 30 minutes a week does not seem like an adequate amount of time to address restrictions. Additionally, when not following up with exercise you could potentially lose the range you gain. The exercise prescription is non-specific, and I would speculate that this article may be something to spin in positive light as to why individualized physical therapy treatment with personalized function exercise is the way to go.
2. Similar to answer one, if you are not following up mobilization with exercise, you may not see as great gains in range of motion. Also, there may be a ceiling effect or participants may start out without compensation but develop this overtime.
3. It doesn’t surprise me given the time constraints of therapy. Again, the provides an argument why specific treatment and manual therapy may be beneficial if provided in a different treatment model.
4. I have utilized ultrasound a handful of times, but I do not see the applicability to this patient population. Others have mentioned tissue depth but I believe ultrasound is more affective for soft tissue injuries.I’d love to again have people share specific examples of “Explain Pain” strategies, analogies, metaphors, stories, approaches that have worked and not worked with this patient and similar.
Read through the 10 Key concepts posted by David Butler and think about ways to address some of these concepts.
https://noijam.com/2017/03/03/supercharging-explain-pain/
Post some thoughts.
http://channel.nationalgeographic.com/brain-games/videos/rubber-hand-experience/
Another pain video post – requested
I would make sure there is a reason/rationale for any of the nerve glides, even on the opposite side, joint work (even away from the region of pain); I’d focus on pain education; make sure pharmocologically he is taking something to decrease the sensitivity. I love the aerobic exercise, laterality training.
I’d be cautious with nerve glides, other strength/flexibility exercises.
Good luck – embrace a challenging patient
Great job everyone – I hope this was helpful for clinical reasoning/decision making with tendinopathy patients.
As for the Gait retraining questions – that is always a challenge .
Mid/fore strike definitely loads more of the achilles complex; but rearfoot striking typically means runners are on the ground longer with pronation into terminal stance, and the achilles works obliquely at propulsion.
So some trial and error, and decision making based on individual foot/gait mechanics.
I’ve had successes and failures with gait re training with this population – but if a larger frontal plane deviation (excessive pronation at terminal stance), they usually do better with cadence/strike pattern cues/changes, just have to progress slow. If less of a frontal plane issue, then they do less better with cadence/foot strike cues.
Great job everyone – I hope that was a helpful activity for clinical decision making with tendinopathy.
Cheers
1. I agree with the overall consensus; if you are finding techniques that are leading to symptom reduction, I would stick with those. If you hit a plateau, it may be something to investigate. We talked recently this weekend about not making a manipulation an ‘event.’ Perhaps working it in as a part of treatment would be most appropriate. If he were to relate this to what was performed at the chiropractor, you could discuss it further.
2. Not quite sure if overpressure is the same as compression, but I agree with August that this may be useful if you were not able to provoke all of his symptoms during the exam. I know it is something that I do not do well, but if you have provoked all the patient’s symptoms and have a good idea of what is going on, providing the patient with symptom relief and exercises is where I would go. You can assess later down the road.
3. If there was an increase in frequency and duration of symptoms, or no change with treatment after several visits, I would rely these findings to the referral physician.
4. It would be hard to tell since there have been several changes. For instance, He could initially have not changed his running pattern. Then with worsening of symptoms, a maladaptive pattern may have created symptoms.
5. To get some buy in to change some of his activity, you could potentially have him perform some of the lifts he is doing at the gym; abet you may not have enough weight (315 lbs is a lot). While I’m not an expert on these techniques, if you were able to provide him with feedback on positioning or form, he may buy into some changes to his routine. It could give you an avenue to discuss the potential of increasing reps at lower weights or incorporating rest days.
6. I have not. Similar to August, I have utilized thoracic techniques for patients with stenosis. And similar to Erik, I’m interested in learning more.
Phase 5 – Sports Specific/Functional
Increase strength/power: Incorporate double limb and single limb squat progressing with weight and repetition to target strength and endurance. Initiate quarter, half, full lunge. Continue to address dynamic stabilization of the hip.
Increase speed of contraction: Potentially initiate a jump progression program starting with reduced weight at total gym or on leg press, double limb to single limb improving push off and landing mechanics.
Specific demands of sport: To address strength continue with or initiate hip and core strengthening program to improve proximal stability. Progress maintaining neutral foot with single limb stance on firm or complaint surface with contralateral leg swing to address movement pattern. Teach dynamic self posterior hip mobilization in lunge or child pose to address hip extension/rotation deficits. Continue with or provide static/dynamic stretching.
Drills: Start push off and sprint drills, should be performed pain free.
Plyometrics: Potential jumping plyometric exercises to improve push off speed and performance, including resisted jumping, squat jumps, single limb vertical jump.
Graduated/progressive return to sport/running: Perform graded treadmill program increasing incline/decline, speed, duration. Gradual return to sport with running in increments dependent on duration or mileage of pain free running.
Phase 6: Maintenance Loading
Off season training: Educate regarding appropriate off season training schedule including gradual increase in milage. If pain returns/persists, reduce training level.
Adequate loading: Continuation of eccentric exercise.
Gait mechanics and gait retraining: Treadmill training with verbal and/or visual feedback (mirror if available) for self correction of training errors starting with level surface progressing with incline/decline and speed.