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Steve, I’ve also come across this dilemma. Why do you think you are timid? For myself, I tend to be timid to introduce a high-velocity passive movement in a population that tends to be slower moving to avoid aggravation. Would you agree?
Laura, very interesting article here. It seems this suggests that we are free to administer the technique that we feel would be best regardless of patient preference. The question asked in the study identified preference, not necessarily fear of a treatment, such as some people may have with manipulation. I wonder if any of these “preferences” were rooted from an aversion as opposed to a partiality and if that would produce any differences.
I’ll focus on the dizziness component of this case. I would want to ask for their reports of dizziness including frequency, severity, triggers, and type/experience. It seems as if the Dizziness handicap inventory would be a simple and effective tool to use to objectify the impact of this dizziness symptom on daily function. Further subjective questioning may help indicate what specific activities trigger the dizziness and guide objective measures. We would want to decipher if this was a cervicogenic dizziness, a vestibular symptom, an exertional tolerance impairment, or any combination of these. A cervical screen including upper cervical tests would be important to perform as well as a Dix-Hallpike and some sort of graded exercise testing. From there we should have a better idea of where to proceed.
I think there are two large changes I’ve seen in my practice:
1) Subjective exam – I am much better at coming out of a subjective exam with more useful information. I now utilize more specific questions and synthesize them to structure and enhance my objective exam. I used to move through the subjective, get essentially the bare minimum and lean on my objective exam. I now see how inefficient and unhelpful this was for myself and the patient.
2) Specific intervention – More specifically a patient-specific intervention. I used to be very general with treatments and shotgun exercises at my patients to fill time when they probably (…definitely) did not need it. Now I am able to have more impairment driven treatments and this has helped me achieve better results and better patient buy-in.
@Barrett and Anna
I love how you guys talk about developing soft skills. I think as we get out of school these first 2-3 years we have been overstuffed with information and a lot of it gets lost as more piles in. Then when we finally get into a clinical setting we’re trying to apply what we can remember and it can become hard to communicate effectively and think about those other pieces of care. Once those start to click practice does get way more fun.I really enjoyed this article. It helped highlight the importance of different aspects of the patient-therapist relationship. A lot of times patients post-op need that reinforcement of expectations and realistic goals. This can involve very touchy conversations and careful navigation.
I think everyone has made great points about this case. Reflecting on the article, perhaps the therapist can start to take the role as the motivator (gently at first). If this patient is nearing return to sport testing, it would be within the normal conversation to talk about sport-specific needs. This could open up a conversation about the sport and may help you gauge her enthusiasm. This may be a more direct communication approach, but if it is started more from goals and treatment perspective maybe it could avoid the emotional aspect until you have more information.
This was a very interesting case. Shows how a healthy amount of skepticism in the absence of a clear clinical pattern can help catch something that was missed.
It seems like a lot of the decision process was based on risk factors, MOI, lack of progress, and again a lack of a pattern. Were you able to reproduce symptoms in the clinical exam at all? Were there features to this case that made sense from the objective exam when reflecting on the ultimate diagnosis?
I think correlational studies do have their place. In the world of nutrition literature correlational studies are commonplace because of the large amount of confounders and behavioral aspects to diet. It is difficult to control for exposure to foods, nutrients, etc. as opposed to our ability to control exposure to an intervention in medical research.
This does not however excuse this study for the oversight of cultural differences, exposure rates, healthcare quality, and the large amount of uncertainty that is associated with COVID-19. A little concerning that the sections on limitations and the interpretation explaining why the results didn’t make sense took up most of the paper.
I find it interesting that they did a follow up at one year and the people in the placebo group didn’t get better. I think 12 months is a pretty long time to have sought other treatment or tried something new.
Good call Barrett. I didn’t think of this. You would think that natural history would have set in. The subjects of this study were people with chronic headaches though, so maybe that explains that.
SNAG Article Questions:
1: I think this was a fair search strategy. It’s broad, and even so, the initial search brought back narrow but helpful results.2a: I have always liked SNAGs in my experience. I use them a lot when cervical ROM is a goal. I do find them somewhat difficult to teach for some patients.
2b: This article seemed to demonstrate significant improvements in ROM and function immediately, in the short term, and in the long term.3: I thought this was a pretty well-done study. Appropriate blinding, a reasonable placebo intervention, and no glaring biases shown. Helen makes a good point about assessing exercise performance, but I feel this would have produced a different error if it was an issue.
Dizziness: I have only treated 1 patient with cervicogenic dizziness. She didn’t have a ROM restriction at the upper cervical region, but the CFRT did reproduce her dizziness. I focused on METs in the CFRT position as well as some motor control training with the laser pointer. This seemed to be helpful, but it is my only experience.
In my experience, the most difficulty lies in finding a daily stress reliever. I feel a lot of the people I see may be able to identify stress but see it as unavoidable: “I can’t stop being a mom,” or don’t have leisure activities when I ask them about what they do for “fun.” I found value in this hand out in the areas with suggestions for activities. This can open deeper conversations about how to make small adjustments in their day to provide a small escape.
I echo Anna and Steven’s points about testing procedures and trying to find a neurological cause of these symptoms.
In addition, another non-MSK differential would be intermittent vascular claudication for which I would likely want to hear that increased activity brought on symptoms. This may be a similar report to statin-induced myopathy, but from my understanding of the article, the myopathy symptoms are more likely in the days following activity as opposed to immediate symptoms onset in IC. Thoughts/contradictions/more info on this differentiation?
Assuming I got to the end of this eval with statin-induced myopathy as a chief concern I would refer back to the physician for potential modification of meds. AJ and I have had discussions during mentored time about these referrals and at one point I had a guide for making these conversations effective. My takeaways were to keep it short, summarize key findings, and suggest the desired action.
Something to the effect of: “I’m seeing Mr. Smith and during our examination, we were able to rule out radicular pain or other musculoskeletal diagnoses. His onset of pain seems to be correlated with his recent change in statin medication. I’m concerned his symptoms may be an adverse side effect. Would a change in medication be a reasonable intervention at this time?”
Before answering the questions, I’m curious:
At what point in this continuum did you see her?
Had she seen any improvements since her symptoms began?1) I believe this case begins with a lot of education. She seems to have undergone the appropriate medical management (i.e. steroids, drops, screening) and is a few months into this process. Figuring out where she is at with this from an emotional standpoint and educating her about the prognosis would be at the top of my list. Clearly PT isn’t groundbreaking in this population, but it seems that exercise may have some positive outcomes. I would start with an HEP of some facial exercises to address weakness and self-massage due to her myofascial restrictions. I don’t think I would feel comfortable seeing this woman frequently in order to attempt 2-3 interventions that have weak evidence, but teaching her ways to use the function she has and potentially improve it on her own is valuable in my opinion. I would likely space appointments out to f/u in 1 week for review, and either biweekly or monthly to monitor symptoms and adjust the POC as necessary.
2) Given that the rate of improvement with natural history is so variable, and likely positive, I’m sure it is difficult to gather good data on this population. If I was seeing this patient, I would find this systematic review to be very helpful as it would teach me more about what the overall treatment options were, and a short summary of whether the interventions. My next move at this point would be to find lower-level research to find appropriate protocols and ideas for exercise progressions.
3) At the base, this pathology is like a peripheral nerve entrapment. Similarly, the outcomes of exercising the affected muscles may or may not be helpful, but in clinic I would apply my philosophy to attempt strengthening in order to gain what can be gained, and abandon it quickly if it didn’t produce results. Also, as mentioned before, I would make an effort to make treatment as home-based as possible so I am not wasting this patient’s resources on a less than stellar treatment.
Subjective – I think Anna had great points about identifying the nature of her pain and the way it behaves. This can tell us a lot about the structure at fault (if there is one).
I would also like to know about the aggs/eases/limitations for this patient. When does she experience this pain? Talking (how long?), chewing (what kind of foods, how long?), brushing her teeth (manual, electric toothbrush?). With the common association of TMD and cervical pain, does she have classic cervical aggs such as rotation, postural intolerance, etc. This will let me know where and when she is functionally limited and how we can ease that with out POC.
Psychosocial – In my experience people are usually accepting of the link between “stress” and TMD. They already associate stress with “tension” in the neck and jaw and this can be an easier sell in terms of education. I want to know more about how this stress affects her and how she’s managed it in the past. Due to her recent move she may have less time allocated to her own pleasure and stress relief activities. This may be a good place to start before making a full psych referral.
Management – **Assuming this case is CS and psychosocial > mechanical** I think this may be a case that is managed best with infrequent visits over a longer period of time. She may need some impairment based treatment that can be easily worked into an HEP, but I think a touch and go approach would be best. It would also help to ensure she took the necessary steps to improve her stress management long term.
1) I see no problem with this. If you attempted to broaden your search with a generic “manipulation” AND “neck pain” you would have drowned in 700 some results. This search is specific and gave you some fair choices.
2) Strengths: Fair exclusion criteria, randomization, fair sample size (although they looked at a lot of outcomes so this may not be very strong?), I think the f/u time fits the goals of the intervention provided
Weaknesses: Lots of outcome measures, A vs. A+B model (more care vs. less care)
3) The results of this study were not overwhelming, but I feel it was a well done study. The within group improvements were fair showing that manipulation definitely has a place in these patient cases, but it may not provide much benefit to spend more time on more manipulations. My take away from this is: manipulate where you feel they need it and move on.
To the points about OA following ACL tear vs ACL-R: I could not find anything that directly compared rates of OA between copers and non-copers, but it seems that both populations experience an increase in knee OA risk. I think it’s more accurate to say that having the surgery would not decrease his risk.
I would not see the need for this guy to be pushed towards surgical intervention at this point. I think about the giant step backwards he would take for a minimum of 6 months following surgery. I think it is absolutely worth addressing whatever strength and motor control deficits that are there and seeing where he is in 5-8 weeks.
As far as what to work on, I agree with everyone that closed chain motor control, especially in task would be most beneficial. I am curious what his quad strength in isolation is given his side to side quality differences with hop testing. I would check this and prioritize a deficit here.
Mind blowing he was deterred from PT. I would love to hear the rationale (or lack there of).