[Taylor Blattenberger]

Great thoughts guys! So…

She did not have any previous shoulder history including pain or dislocations. No feeling of instability, just sharp pain.

When she spoke about the event she described her shoulder being in a resting position by her side. It didn’t seem as if she was in a “odd” or “vulnerable” position.

Symptoms seemed to change over the year, but the c/c at this point was a specific point at the deltoid tuberosity. At this point her symptoms had plateaued. It seems to have gotten better, but now that she is doing activities that aggravate the shoulder such as her exercise routine it hasn’t changed much. She is trying to modify workouts – wall push ups instead of regular push ups.

More on the workouts – she had no pain with bicep curls, overhead tricep extensions. She also did mention a pilates like move where she had to bear weight on her R hand and BLE which caused increased symptoms.

[Taylor Blattenberger]

1) I really enjoyed the review of neural structures in the foot and how they may present when they become symptomatic. Seeing all that again really broadened my differential diagnosis list for the foot especially when faced with a difficult plantar heel pain case. I actually utilized this this week. It didn’t produce any positives, but I felt better that I ruled these things out.

2) Chris Johnson did a great job of simplifying the analysis of running and really highlighting the glaring things we should focus on vs. the things that may not be important to change. I don’t see many runners in my current practice, but I will keep the S’s in my back pocket if I am ever treating this population.

3) I really liked the overview of different functional tests and understanding the way he used them to evaluate readiness to run. I have used some hopping and pogos in previous cases, but using specific tests to preferentially stress other tissues is something I have lacked. I’d like to use these more in my own practice.

[Taylor Blattenberger]

Anna,

That must have been a very challenging eval! I don’t blame you at all for taking that approach. I feel that was very well handled and I’m glad she was receptive to the education in future sessions. Definitely a great way of blending her expectations with your educational agenda as her treating therapist.

I honestly can’t say I would have done much differently. Keeping in line with the article I know I would have focused on the fact that her prognosis seemed good and that “these things get better.” I’m sure avoiding the education early also helped strengthen your alliance with her. Back to your original point, she probably didn’t need more info, she needed reassurance.

[Taylor Blattenberger]

Anna,

That’s such a difficult predicament to be in. On one hand you want to convey accurate information and supply your narrative to your treatment. Although, you have the ability to turn what is usually a nocebo into a placebo for your treatment modality. Now her positive beliefs can be coupled with what you believe will be a beneficial treatment and enhance her outcomes.

What are your thoughts about the long term effects of feeding into this belief? My concern is that she connects pain with her disc being “out again” and would seek more medical treatment in the future. What did your education look like over the time and what did she make of it?

[Taylor Blattenberger]

1) What do you think about my search strategy? Tips/pointers that you’ve found helpful for other literature searches?
One thing I found helpful when going over lit searches with AJ was using MESH headings when the regular search terms aren’t giving you what you want. In my opinion, it’s not the easiest thing to use, but it did provide some different results.

2) Read through my summary and the article, then let’s talk about statistics:
– What do you think about their findings in the results section?
I honestly have a tough time following the results because of how different each analysis is. The tables are talking about the differences at each point in the study, and they did not outline the comparisons within and between groups very clearly. The graphs were an attempt to illustrate this, but the disability graph, fig 1, was an error as it was a duplicate of the NRS graph in fig 3. Overall, the author did not follow a clear path with her results and discussion.
– Did they draw appropriate conclusions based on the statistics?
To be fair, the final conclusion did only mention objective ROM improvements which was the one clear difference between groups. This comes after a great deal of speculation around the other subjective improvements. One issue I did have with this conclusion is that these measurements were never presented in the results. Curious how significant these were.
– What are your thoughts on statistically significant vs clinically significant?
This is something I regularly look for in articles I read because it is very easy to slip past some bias with small scale, but statistically significant findings. I think this was more of an afterthought for this particular article for me as there was such little consistency in the first place.

3) Any other general opinions on the article?
Overall I found this article difficult to follow and if you asked me “what did these results mean?” I would probably take away that the placebo intervention was just as effective as whole besides pain ratings.

[Taylor Blattenberger]

Great points Barrett. I think this article highlights a ton of principles we should be applying to our practice in general as opposed to just the SIJ. We need to consistently toe the line of “I think I know how to help your pain and here’s why,” and not sounding like the patient has a serious medical issue. Messages of fragility are unfortunately a consistent theme of orthopedic practice and we now know they have a harmful lasting effect. That being said, part of our jobs is to help people cope with MSK pain and potentially provide relief in some way. Typically we can link some tissue to the complaints, and want to educate our patients about what we think is going on.

How do you all relay your messages about movement diagnoses or tissues at fault without noceboing your patients?

[Taylor Blattenberger]

1)Looking at the body chart, what is your main hypothesis and 1-2 differential diagnoses?
Cervical facet arthropathy
Cervical myofascial strain
Mid cervical disc pathology

2)Now utilizing the subjective information provided, does your primary hypothesis change? If so what is your primary hypothesis and differentials?
At this point my primary shifts to myofascial given the MOI and c/o “tightness” and difficulty with strenuous UE activities vs sustained positions or specific neck movements/positions.

3)After reading the objective findings, is there a specific pattern forming which can help rule in/rule out some of the differentials? Which information seems to lead towards your hypothesis?
Not a straight forward pattern, but the objective findings shift my primary back to facet arthropathy given that SB positions to the L aggravate L sided neck pain. Hypomobilities in joint assessment also point towards a facet problem. ***

His resisted testing did not make it seem as if there was much myofascial involvement. There was no note of TTP in any of the myofascial structures around the neck like UT, LS, SCM, etc so I assume those were all negative. This is something I would expect to come up (+) in a myofascial problem.

4)What else would you have asked in the subjective and/or what other testing would you have performed?
Subjective:
-How have symptoms changed over the past 6 months? worse/better/more diffuse/fluctuating?
-What specific job related duties or recreational activities are difficult for him to complete?
-How is his work life affected by this? – aggs + severity + psychosocial
Objective:
-Compression/Distraction in different angles to rule out/in disc pathology
-Stretch of myofascial tissue – with this high on my differentials I would want to know how the mm responded to full stretch
** was joint mobility painful, or only hypomobile?

• This reply was modified 4 years, 5 months ago by Taylor Blattenberger.

[Taylor Blattenberger]

1. Based on the body chart and subjective, what is your primary hypothesis and top 2-3 differentials?
-**PFPS**
-Patellar Tendinopathy
-Tibial plateau Stress Fx
-L3-4 radic

2. With the subjective and objective information, does this patient fit a clinical pattern?
At this point I cannot identify a clinical pattern, but I would lean towards PFPS given the altered movement patterns and the effect this may have on the PFJ during cyclic loading.

3. Do you feel like you need more subjective/objective information for this case, and if so, what?
Subjective –
Running experience?
Recent change in running volume/intensity?
Does she only use a treadmill? – has this changed at all?
Any other training she participates in
Symptoms like this before?

Objective –
-Knee resisted testing – At different degrees of knee flexion for provocation
-Patella Compression test
-Step down – does knee over toe positioning change symptoms in SL squat/CKC knee bend?
-Heel drop – At this point there’s not much to rule out a fracture and this may provide some info
-Running assessment?

4. What is your treatment for day 1 and what are you reassessing next visit
At this point the only true impairments are the hip weaknesses and the altered mechanics with squat/SL/hop. I would address the hip weakness with a very isolated movement such as clams or sidelying abd, and reassess strength, and reassess squat or SL squat. This may improve mechanics or at the least provide information about whether this is a true strength issue, an “activation”/motor control issue, or if more in task motor control training is something to attempt in the future.

[Taylor Blattenberger]

Helen,

I agree, this is a difficult area to research. The broad topic of “within session changes” can take a lot of forms which this article highlighted well. Are we looking for more range? More strength? Less pain? Better movement? To lump these all together may not be an effective means to assess the concept as a whole.

To Anna’s point we absolutely need to tailor our treatment sessions to promote carryover and goal directed outcomes. In-session pain relief is not enough for most patients to reach their functional goals, yet that is typically what I’m after in an assess-reassess scenario.

I’m curious, what are you all typically assessing-reassessing if/when you look for in session changes?

[Taylor Blattenberger]

1) Looking ONLY at the body chart, what is your primary hypothesis?
-Hip OA

2) Looking at the body chart AND subjective exam, now what is your primary hypothesis? Next 2-3 differentials?
-Hip OA

-Greater Trochanteric Pain syndrome
-Labral Tear
-Upper Lumbar radic

3) What are some other questions you could have asked to help rule in/rule out your hypotheses?
-Has this been getting better/worse?
-What part of going up stairs hurts? Lifting the leg, pushing on the step, having the hip in ext while stepping up on the other side?
-How does the pain behave? – Start lateral and move distal? Mostly anterior thigh and rarely lateral?
-At what point is squatting painful? – full depth, entire movement, sustained squat?

4) Does the objective information/patient presentation make you think of a particular diagnosis?
-Seems like OA due to ROM loss, special testing results, and WB intolerance.

5) What would be your first thought on treatment for this patient?
– For this patient I would employ light AROM and AAROM exercises into limited ROMs to improve ROM impairment, encourage active participation in treatment, and ensure she was getting ROM work frequently at home. Specifically I like a supine knee rock into ER/IR (due to IR limitation) and SKTC.

[Taylor Blattenberger]

Thanks Anna,

I definitely did not find any characteristics that I would say identified a “extensive care” population. Just a thought about our interventions still having a place in some patients, just (based on this study) not all.

Other studies about the affect of manual therapy or exercise have been A vs A+B or pitting different styles of the intervention against each other. This is the only study that has a realistic sham in place. All that previous studies, including this one, have shown is that typically this gets better with time. I’d be curious to see a future study replicate something similar to this with a qualitative aspect. The authors mention contact with a care provider being beneficial, but it would be interesting to understand patient perspectives to reinforce this.

[Taylor Blattenberger]

Reading this article was a great review of the PEDro scale. I feel like doing a quick screen of these items provides a lot of insight on the strength of an article and where the holes may be. The authors did a great job of checking all boxes they could control and even looked for other confounders like activity level, comorbidities, and previous treatments.

From a clinical perspective, this is definitely an article to cause reflection. If focused PT did no better than ultrasound gel can we ethically offer treatment to this population? Are we wasting the patient’s time trying to improve strength and ROM when it may improve on its own over time?

In reflection I think about the natural history of OA and the fact that it typically waxes and wanes over time. People usually seek care when it is at a more severe point. Then, whether due to regression to the mean or in response to treatment methods, patients’ symptoms improve they are able to continue activity. Maybe we should take the role of an educator with these patients rather than trying to treat each one with an extensive protocol. We should focus on providing education about pain, osteoarthritis, prognosis, activity recommendations, etc. There’s a lot of information that we can provide this population to help them cope with their symptoms easier.

Does that mean that every patient with OA can’t benefit from some manual techniques, exercises, whatever other form of PT we can provide? Not necessarily. Maybe there’s a subgroup of patients that would benefit from more extensive PT.

[Taylor Blattenberger]

One thing I took from this video was the importance of committing to a hypothesis. Watching the prediction video made me reflect on my previous experiences learning about predictive processing and Bayes’ Theorem. Essentially, these ideas are centered around the idea that we are constantly updating our hypotheses with new information as it is presented to us and it is synthesized with our past knowledge. This way of thinking can be very helpful as stated in the video, but how can you update your hypothesis if there isn’t anything there in the first place? In order to change a belief you have to have one.

[Taylor Blattenberger]

Thanks a lot guys! Great thoughts about neurodynamics, especially as it pertains to a possible peripheral nerve pathology. Hopefully I can shed some more light on these and other questions you might have tomorrow!

[Taylor Blattenberger]

Questions:
1) Could have had her fill out an NDI, but the QuickDASH does have relevant items for this case. Great job looking for her different symptoms, I want to know more about the way they come on. Is it immediately? After 10 min? An hour? Do they all start at the same time, or does the neck hurt first, then the shoulder? That sort of thing.
2) Great list, Maybe add thoracic facet referral.
3) I liked the level of rigor you used in your exam. ROMs provoked almost all symptoms (besides headache) and it may not have been necessary to do too much else at this time. With the info presented I’m having a tough time distinguishing this as a disc pathology or myofascial. Did you do compression? I also want to see what the neck ROM looks like when the myofascial structures are unweighted. That would be a quick test to differentiate the 2.
4) Cervical myofascial strain + Subacromial pain syndrome – biceps tendon and RC tendon involved
5) For a 28 yo female with neck pain post MVA, are thoracic mobilizations as effective as cervical mobilizations at decreasing pain with active movement. – You describe this patient as highly irritable, so what is the utility of treating away from the most irritable region. Full disclaimer, if this was my patient and this was my question I would assess the T/S for hypomobilities first.

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