[Taylor Blattenberger]

The part of this video that spoke to me most was the highlight of biases. I find myself in premature closure frequently in an effort to move to treatment and convince myself that I have a better idea of what is going on than I do. In this way I need to improve my shift to system 2 to complete my entire evaluation and understand the details I am missing, or at least prove that they are not there.

[Taylor Blattenberger]

For this patient I don’t believe surgery would be a realistic option, at least in the short term. I have seen 4 people that have undergone the mini tightrope procedure (not the full way through, but at different points in rehab). When the rehab is completed I have noticed patients are typically satisfied, but the protocol is very restrictive, especially in the first few months. From my experience the protocol limits “excessive” gripping and lifting with the involved hand for at least 2 months allowing AROM only. With this woman needing to lift and care for her young granddaughter, this may not be feasible.

She would be much better off attempting conservative management. I think this case has the characteristics of an acute overuse injury as a new repetitive stressor is directly correlated with symptom onset and progression. I think bracing would be a great option for this patient to limit CMC movement, especially when she is doing more strenuous activity such as lifting her granddaughter and performing heavy ADLs.

[Taylor Blattenberger]

I agree that this article move special tests even further down the list. I also loved that the author made a point that I had thought to myself before: If pathological changes are present on imaging of non-painful tissue, how do we truly identify how valid a test is?

In terms of abandoning tests all together, I think that is a mistake. Some tests provide valuable information such as specific positions of discomfort, an approximation of tissue irritability, etc. I think the difference is what YOU think the test is telling you. They aren’t telling you a specific pathology is present, but perhaps they give you a better clinical picture of movement and patient experience.

[Taylor Blattenberger]

Barrett – I absolutely agree with your critic of social media. It is an extremely volatile medium of communication and even in a professional setting can quickly dissolve into echo chambers and clique wars.

You also bring a good point to finding reliable sources on social media. See: Kardashian Index for a somewhat satirical, but relevant point to this discussion.

I do think this metric can have significant value to the academic world. The scope of academic literature reaches beyond research application. Clinicians use this research to update their practice and apply new techniques. If something is being circulated at the bottom of the traditional research pyramid (us in clinical practice), that should be reflected. It will give a look into what things are driving clinical practice and what trends are being formed.

Even if the numbers are inflated by gimmicky influencers, this measure will still provide insight to what is rising to the top and why things are trending in certain ways.

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[Taylor Blattenberger]

I think this would definitely be a treat and refer case. Care would not be completed at the time of the referral.

I’m not 100% sure, but from what I’ve been reading, MRI or CT seem to be the most reliable ways to identify AVN in the hand. Anyone have any information conflicting with this?

Bracing would be an option in this pt, but could take many forms. Without making too many conditional applications: It would be beneficial for him to wear a brace limiting extension when he is doing activities that aggravate his wrist throughout his normal day. It could also be helpful to keep him performing some sort of practice such as putting or light chipping with a passive restraint. If this limits a painful ROM and allows more function in the short term, I think it is valuable.

[Taylor Blattenberger]

1) I am also admittedly poor at search strategy overall. I find I do better when starting specific and then pulling words to broaden my search. Past an abstract I go straight to the methods to figure out the sample size, study design, and blinding to see how well done the study is.

2) They don’t seem “functional” but I think that comes with the territory of “lumbar stabilization.” I feel like these are things that most clinicians would call “core stability” and they outline a clear progression to follow. Maybe not what I would do with my patients, but a fair guide to follow in a research study.

3) Did some digging in their sources as well as on my own. I’ve always heard in passing the surface EMG is mediocre at best, especially in the trunk, but couldn’t back it up. As far as reliability it seems it can be fairly reliable, but only in partial contractions. Things get less reliable when you utilize max trunk contractions (which they did in this study). Also somewhat interested to know what the “intra-rater reliability test for measurement of muscle activity assessed by the assessor” was.

As far as whether or not it was worth assessing at all, clinically probably not, but I can see them looking for some sort of biologic plausibility that “I train deep core mm therefore they work better.” This doesn’t prove out though as the PNF exercises provided similar improvements (however valid they may be).

4) Great call on the participants Anna. I didn’t see that at first. To me there’s a difference between C-LBP x1 year vs 5 years +.

Overall, seems like one more piece of evidence that specific TrA and multifidus training doesn’t do much better than more general exercise interventions.

[Taylor Blattenberger]

I think Helen and Steve did a great job outlining some differential diagnoses and testing procedures.

It seems that all his c/c’s involve wrist extension (gripping heavy objects, weightbearing, golf swing/ground impact assuming he is RHD) which makes me more suspicious of a carpal instability. I would want to rule out traction, axial load, and active/resisted movements as stand alone aggs subjectively and objectively:
Sub:
-Pain with turning a doorknob (resisted mov’t w/o wrist ext)
-Pain with writing (repetitive resisted mov’t w/o wrist ext)
-Pain with pulling a door open (traction without need for power grip)

Obj:
WB on palm (ext) vs fist (neutral)
APR exam to examine A/PROM and confirm my suspicion of a passive restraint and rule out contractile involvement

In terms of urgent management, I agree with Steve in his stability question driving imaging decisions. Given the chronicity of this process, if the symptoms were worsening I would be concerned of AVN and would recommend imaging. Personally I think this report and the risk of prolonged pathology warrant this decision regardless of objective findings. To my knowledge, I don’t have anything to lean on to rule out this potentially sinister pathology without imaging. Does anyone have thoughts on this?

[Taylor Blattenberger]

Awesome guys! Thanks so much for the questions and ideas.

Obviously my exam left me with more questions than answers and I wanted to make part of my second day a bit more evaluation to try and clear the mud. What I found were again, more questions. Day 2 she had (+) H-K and (+) painful arc and her ER was now mildly painful. Impingement? I also cleared her C-spine and performed a neuro exam as I realize my negligence, and got all (-)s. Finally, I tested her grip strength which revealed painless weakness (50% of her unaffected and non-dominant hand). What???

I was so lost, and I feel I may have shown this in my mannerisms because I noticed some confusion from the patient as well. I ended up taking a step back and moving forward much as Steve described. It wasn’t the neck, and probably wasn’t the elbow. A majority of her symptoms were provoked with shoulder movements so I was confident it was some sort of shoulder pathology.

All things considered, the special tests I performed did not help me much. If anything they hurt my treatment at first. Although, if they came back with a recognizable pattern I would have been able to be more specific in my treatment selections and maybe make some quicker improvements. I feel that the use of these tests should be taken with a large grain of salt. If a pattern exists, great! We can move quickly through an algorithm. But if it doesn’t, recognize the poor psychometrics and potential for concomitant pathology. Treat the impairments, be as specific as possible, and reassess, reassess, reassess.

• This reply was modified 4 years, 3 months ago by Taylor Blattenberger.

[Taylor Blattenberger]

First of all, this was a well written article that presented information very well. I felt myself have small shifts of opinion multiple times as reading. When I review my thoughts on the test, I think how the performance and results of the test would change my treatment route with a patient.

If performed and positive for symptoms: Is this patient at risk of dissection, or are their other vessels not providing collateral flow? Is this even a vascular response, or is it a vestibular or cervicogenic dizziness/headache?

A negative result is even less helpful: Just because there are no symptoms, does not indicate that the vessel being loaded is healthy. They could still be at a higher risk of dissection.

So, as I understand it now, I’ll either get a negative and be skeptical, or get a positive and be slightly more skeptical. MAYBE a positive test coupled with PMH of vascular disease and other subjective reports would push me even further from a technique, but I cannot see myself using this test to make myself more comfortable with performing a technique that would be potentially compromising.

[Taylor Blattenberger]

For example, RTC isometrics can be done in various ways (different angles, speed of movement, etc.) that can be viewed as “progressions” of the exercise that we can choose to prescribe if we feel like it is appropriate for that patient but are still within the protocol that is given.

Love this Anna! I do this a ton with RC isometrics in particular. Walkouts, rhythmic stabilization type exercises, ROM in other planes while maintaining isometric ER, etc. Very easy to forget the small progressions or variations that can make a big difference.

[Taylor Blattenberger]

So I did not clear the cervical spine. I didn’t move forward with this because all the aggs seemed to be shoulder related and my neck questions came up negative. In retrospect I could have smashed the cluster and removed any doubt there.

I attempted to utilize the impingement cluster to rule in my primary post-subjective differential, but got 0/3. In fact I was very perplexed to come up with (-) ER testing. I really went looking for something here and got proved wrong. So I had to move on.

From there I attempted to think more about the aggravating factors and what tissues were being stressed. I thought about the biceps (+) I got earlier and the sensitivity to extension (dips) horizontal abduction (push ups) and weight bearing in general. With this I pivoted to anterior instability and possible labral pathology.

I started with apprehension/relocation more out of an extension of my PROM exam of shoulder IR/ER at 90. I noted the pain, but did not take this as a great * finding. I chose compressive labral ST due to the WB sensitivity. This was somewhat positive and the fact that the grind was (+) with an anterior GH head shift fit my other findings.

[Taylor Blattenberger]

Probably could have clarified my thoughts prior to adding the objective:
So my top presubjective differentials for this patient were:
-Adhesive Capsulitis
-Impingement
-RC tear
-Labrum

After hearing the lack of “Stiffness” and she gestured a few times that showed her AROM was at least not severely limited, I moved adhesive capsulitis down my list. After all subjective questioning I was thinking more impingement due to the contractile aggs and a position of flexion/IR being provocative. I also added lateral epicondylalgia secondary to the odd elbow/grip reports.

In terms of elbow clearing and the positives there:
When I cleared the elbow I felt as if the findings were more biceps related and felt I could move away from the “elbow” and relate this more to proximal issues. Important to note that I tested all wrist motions with resistance in lengthened positions so there was no indication of a contractile pathology here.

[Taylor Blattenberger]

Here you go guys!

Let me know what you think and what I may have missed. Spoiler alert: It was NOT what I expected to see.

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[Taylor Blattenberger]

The transition of symptoms seemed to happen in the summer. She felt as if the gripping issue (weakness>pain) was short lived compared to the long standing shoulder symptoms.

As far as other factors with the “bump” – The way she described it, it seemed mid humerus, and no known report of anything else that went on that day. I didn’t explore this much more at the time.

No prior treatment nor imaging

As for recent changes in activity, the workout routine began as some point in the early fall. Change in symptoms may have been related to this, but she didn’t seem to think so.

I did ask about sustained positions, reading, driving, computer work… all these came up negative and she related all her symptoms to arm movements (shoulder movements more recently).

I’ll share the objective tomorrow afternoon.

Thanks everyone!

[Taylor Blattenberger]

When I was working in Northern Virginia I saw a HUGE variation in post-op protocols. The one that sticks in my head is when I was treating 2 different RC repairs of the same technique. One surgeon wanted isometrics initiated at 4-6 weeks, the other restricted any resisted movements until 15 weeks. In this case I did contact the surgeon because I didn’t agree with waiting so long and felt the patient could progress. He told me he thought the complications of re-tear outweighed the benefits of earlier strengthening. I obliged to his request as I tend to defer (especially since I was only a few months out of school at this point).If I am provided a specific protocol following a surgical procedure I tend to adhere close to it as a guide. It is an extension of the surgeon’s clinical decisions. While we have a duty to advocate for better treatments including post-operative rehab, I feel it needs to come with careful and prompt interprofessional communication.

Anecdote aside, when I was at the VPTA student conclave a few years back I sat in on a presentation that talked about being bigger than the post-op protocol. The speaker talked a lot about referring back to tissue healing times and using these to guide our rehab. Having a good understanding of what tissues are disrupted and vulnerable following a procedure helps to provide initial limits and then allows us to use our understanding of biology, biomechanics, and exercise progression to guide people forward.

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