[Stephanie Roane]

I agree with AJ. She stated she didn’t want to bend to pick up something off the floor when asked but then she did a squat and forward flexion. I would of started my education at that moment while being sensitive to her beliefs about bending. Again, I don’t think her obj exam necessarily completely validated a hypersensitive/catastrophic presentation due to the patterning therefore I would of discussed the natural history of low back pain and that her exacerbation’s are not necessarily uncommon. Looking forward to a more in-depth discussion at lunch.

[Stephanie Roane]

Hey Justin,

Nice collection of information. I think your exam sounds pretty thorough. I had the exact same thought in my head….go for the low hanging fruit; which in my opinion would be a lateral heel wedge. Sounds like this guy is a big believer in product assistance (hokas, powerstep orthotics, etc.). One additional item I like to screen in runners is mid foot mobility with movement in the transverse plane. So have him stand in bilateral stance and rotate his upper quarter each direction to quickly screen how much tibial internal/external rotation is achievable as well as how much pronation/supination occurs. I would have likely thrown a lateral wedge in his shoe first day. There’s probably no convincing this guy to ditch his orthotics to promote midfoot pronataion which sounds like he needs more of so I would place the lateral wedge right under the powerstep to hopefully gain more rearfoot valgus/knee valgus to gap the medial tibiofemoral compartment. The only other thing I would do day one is some easy first ray stabilization exercises to train out of lateral column loading. Encourage him to go run per usual and follow-back up and reassess. I think he would buy in to that approach since he was very connected with his imaging and had good success in the past with orthotic use and new shoes.

Keep us posted! Thanks for sharing.

Steph

[Stephanie Roane]

Hey Tyler- just a couple questions in case I can’t make it to your journal club.

You stated his first onset of LBP was in 2010, what has his management strategies been since that time? Has he seen Ortho, been to PT/Chiropracter, injections/imaging, self managing with any other exercise program other than running?

What are his beliefs about his LBP and the recurrent nature? Learning this is key to identify the best way to educate and guide your treatments, discussions, and plan of care.

You mentioned he enjoys running to manage stress; Did you watch him run to see if running may be a contributing factor since you noted his lordotic posture? Think specificty. You may be able to go directly to these activities and clear up a majority of the contributing factors to his chief complaints.

It looks like you cleared his Hips/SI, does that include mobility? Does he have any joint limitations or soft tissue restrictions around his hips/pelvis that may be contributing to his low back posture.

You initiated his HEP in supine and quadruped. Any reason you didn’t initiate lumbar stabilization in standing since you didn’t list standing/walking (load intolerant features) as an aggravating activity? I’m aware there’s a progression to everything however if we’re thinking specificty of treatment, it may be that you can skip supine/quad stabilization and go directly to standing with education on pelvic/lumbar posturing prior to loading. May be successful, may not be but I feel with what you presented it doesn’t appear contraindicated to his symptoms.

Sorry for the last minute questions. Looking forward to discussing your case more.

[Stephanie Roane]

Hey guys- Just to quickly introduce myself, I’m a former resident and am back working at UVA-Healthsouth.

I sat in on the Journal club discussion and spoke to some of the questions surrounding normative data when utilizing the Recognise app. I very recently evaluated a worker’s comp patient that was referred for CRPS so did some recent reading to catch myself up on treating this condition as “true CRPS” isn’t that common for me to see in the clinic.

If you go to the Graded Motor Imagery website from the Noigroup you can find ‘normal’ results they suggest to guide you with your patient as they practice left/right discrimination … Graded Motor Imagery

This is directly from the website…

So what is normal
-Left/right judgement tasks are required to fall within a certain range of speed (average response time in seconds) and accuracy (percentage of correct answers) to be considered as normal.

Our broad suggestions for normal responses to a left/right discrimination test are:

-Accuracy of 80% and above.
-A speed of 1.6 seconds +/- 0.5 sec appears quite normal for necks and backs.
-Hands and feet are a little slower with an average speed of 2 seconds +/- 0.5 sec.
-Based on these figures we would suggest that around 2 seconds is quite normal for other body parts such as knees and shoulders.
-Accuracies and response times should be reasonably equal for the left and right.
-Results should be stable (eg they don’t fade out with stress) and are consistent for at least a week.
-A judgement will also be needed on the personal relevancy of the responses. For example, minor left/right discrimination changes may not be so relevant in a person who has a severe pain related incapacity whereas they may be more relevant in a person with a much more minor problem. This is a clinical reasoning judgement.

NOTE: these ‘normal’ results are based on studies of hundreds of people and act as a guide only. There may be reasons why, after months of practise, you still find it impossible to get results within these normal ranges. Aim for the normal range and give it a real go but don’t be upset if you can’t get there!

It’s certainly worthwhile to check out their website which is supporting information to their Graded Motor Imagery Handbook. Great job with the case. Hope you guys find this helpful.

[Stephanie Roane]

Hey Nick,

I feel like I’ve heard of this test but have not used it clinically myself. Sounds like a nice diagnostic test to utilize. I have a couple hip patient’s that would fit the inclusion criteria in my caseload that I have in mind to try it on. Unfortunately I’m not blinded to their symptomatic hip, but I’ll let you know if I find it useful. However the change of only 10cm from the hold position is pretty insignificant in my eyes. Seems like there would be a lot of error in assessing only that min amount of movement. But I’ll let you know how it goes.

Sorry to just jump on board with this discussion forum several months later. Good post and articles. Thanks for posting.

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