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Are We Dismissing The Significance Of Pathoanatomical Findings Too Quickly?

10/10/2016

1 Comment

 
hen I was in my residency, much of the basis of my clinical reasoning and assessment was based on pathoanatomical diagnosis. I would try to determine if the source of low back pain was a herniated disc, spinal stenosis, a combination, or something else entirely. Towards the end of my residency, I was introduced to the advancements of pain science research by Dr. E at The Manual Therapist. It was freeing in some ways. I didn't have to try so hard to diagnose each patient and look for the evidence-backed treatment options. My evaluations became standardized and based partially off repeated motions. I altered my treatment based off patient response and didn't necessarily have to follow the "rules" of anatomy. Instead, my evaluation and treatment focused more on the nervous system and altering the threat level.
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One of the arguments against a system like this centers around the issue of repetitive microtrauama. Sahrmann has built her Movement Impairment Syndromes (MIS) theory off the belief that repetitive microtrauma and prolonged postures via abnormal movement patterns are responsible for developing abnormal bone growth (via Wolff's Law), degeneration, and then pain. With the development of pain science research, we have learned that there is no correlation between abnormal anatomical findings in imaging and pain. In fact, no long-term study has found repeated motions to directly cause abnormal bone formation. That being said, we must remember certain diagnoses which are directly associated with repetitive microtrauma. For example, spondylolistheses and stress fractures. Now I did discuss last week that spondylolistheses can be found in asymptomatic individuals, but there are cases where they are associated with significant medical problems. Likewise, should a stress fracture not be dealt with in a timely manner, it could lead to bigger issues.

So how should we consider pathology? With research pointing more and more towards dismissing pathological findings on imaging, the tendency is to move towards a system completely devoid of it. While this is tempting (as it is easier), there are certain conditions that we should be aware for potential relevance. Now it is not necessary to have imaging to support these conclusions, but instead we should use patient presentation and response to dictate our management. Should a patient with low back/LE pain and/or N&T present with bowel and bladder issues or saddle anesthesia, refer the patient to imaging. In general, if you are not making progress with a patient after a month of treatment they should be referred back to the doctor. There are certain conditions that mandate being aware of pathology and for that reason alone, we shouldn't be so quick to abandon them.

-Dr. Chris Fox, PT, DPT. OCS

If you are looking to improve upon your clinical skills, orthopaedic knowledge and clinical decision making, consider joining OPTIM's COMT program. With OPTIM, you can expect a residency-like learning experience without breaking the bank, all while learning from highly skilled physical therapists. Check out optimfellowship.com for more information!
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1 Comment
Robbie Horstman
10/11/2016 06:31:06 pm

Good food for thought. I approach the concept with my gut feeling as my first indicator. I see at least a few patients daily with whom I use pain science education minimally. There are also those with whom I spend 75% of treatment time on it. Presentation is important, but so are patient beliefs/misbeliefs. A thoughtful, discerning approach is necessary; there are cases where pathoanatomy is 80%... Others where it's 5%... After all, a compound fracture will hurt at some point :)

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  • Home
  • About Us
  • Insider Access
    • About Insider Access
  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
    • Physical Therapist Consultant Course
    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test