Shweta Subramani 0:00
Welcome to the therapy insights resource roadmap show where we learn how to use the resources inside the Access Pass. If you’re subscribed to our resource library, you have instant access to all of our resources that we’re talking about today. If you’re not a member, you can get started today by heading to therapyinsights.com. If you’re listening to this episode on a podcast or watching this video on YouTube and you want to official CEU credit, head to therapyinsights.com and click on CEUs, fill out the form for the PT resource roadmap Show episode number four, to get your certificate of completion. I’m your host Shweta, we also have our therapy insights writers Ross and Troy with us. Hey, everyone.
Ross Eckstein 0:42
Hi
Troy Adam 0:43
Hey.
Shweta Subramani 0:43
So really quick, this show is being offered for CEUs, so we need to verbalize our disclosures. All of us here are being paid by therapy insights to run the show. So let’s get started. We have a great lineup of resources this month from what is psoriatic arthritis?, sleeping positions for people with spinal pain, carpal anatomy and diagnostic resource for clinicians to what is Huntington’s disease and should I use hot or cold?
Shweta Subramani 1:12
The first resource that we’re going to dive into is what is psoriatic arthritis? and Ross wrote this piece, so I will let Ross talk about it.
Ross Eckstein 1:23
Yeah, so this piece is designed as a handout that can be given to people with psoriatic arthritis. If they’ve been diagnosed by the rheumatologist and they’re in PT, or OT, you can give them this to just kind of explain what it is and what to expect. And it’s kind of written with the client in mind, but you also can get a lot of good information from it as a clinician as well. So it talks about what psoriatic arthritis is, and how it’s a autoimmune condition characterized by joint pain and skin and nail changes, about 80% of people have psoriasis with it, and this typically, is near the joints with psoriatic arthritis. And then around half or a little over half have nail disease as well. It can cause enthesitis, or tendon pain where the tendon hooks in near the bone and can also cause axial spondyloarthritis, which is similar to ankylosing spondylitis. And there is a lot of overlap in some of the symptom presentation between the two disorders as well. So it can affect the sacroiliac joints as well. It can cause swelling of the fingers and toes as well and uveitis or inflammation of the eyes or inflammatory bowel problems as well. And there’s a pretty big spectrum and how people present with psoriatic arthritis and from what I read, it’s probably very under diagnosed and there’s some screening studies where they screen people for this disorder and about 50% of cases have not been identified. And it’s probably further complicated by fact that not everyone gets psoriasis or maybe they get some really mild psoriasis and and so it can be missed very easily. And it can mimic other types of arthritis such as rheumatoid arthritis. Typically, psoriatic arthritis is a oligomer arthritis meaning it affects four or fewer joints whereas rheumatoid arthritis is a polyarthritis mean it affects more than five joints, and typically rheumatoid arthritis affects some of the smaller joints in the hand, whereas psoriatic arthritis from my understanding is more likely to affect some of the larger joints. And then rheumatoid arthritis does not affect doesn’t cause that enthesitis or it doesn’t affect the spine as often and doesn’t have the skin and nail issues either. So it’s typically diagnosed by a rheumatologist and they consider medical history symptom presentation, psoriatic arthritis on imaging, they, you may see new bone formation near joints, which is different from rheumatoid arthritis where you’re more likely to see erosion, around bone or around joints. And then laboratory tests are actually not incredibly helpful for psoriatic arthritis. And some of the tests for systemic inflammation are only elevated in about half of cases. So it’s a challenging diagnosis. As far as treatment, it’s recommended to get early detection and treatment. So if it’s something that you might suspect, as a clinician can be good to refer that out or have a discussion with the primary care provider or the rheumatologist if there’s one involved and typically a multidisciplinary approach is used for treating it. Rheumatologists are kind of the head of the team for that, but physical therapists, occupational therapists, podiatrists, dermatologists, ophthalmologists, if there’s eye inflammation and gastroenterologists can all be involved depending on what sort of spectrum of symptoms you run into with psoriatic arthritis. I didn’t dive into what specific drugs might be used very much, but there are some drugs available. And that can include anti inflammatory drugs, and topical treatments for the psoriasis. And then there’s also disease modifying and biologic drugs as well that are available. There’s not a lot of evidence for the optimal way to re rehab people with psoriatic arthritis. And we don’t really know the optimal exercise guidelines, but typically strengthening, range of motion and aerobic exercise is recommended. We know that in general, people with inflammatory arthritis tend to have lower disease activity scores, if they are regularly exercising, and psoriatic arthritis does predispose you to some cardio respiratory problems as well and heart disease and so aerobic exercise just kind of makes sense from that standpoint. And there’s strong evidence that exercise has benefits for axial spondyloarthritis and psoriatic arthritis is kind of in that family of disorders that can cause that axial spondyloarthritis, so and it’s associated with other problems, such as obesity, which increases the risk of getting psoriatic arthritis. Lower activity levels are also associated with an increased risk of developing psoriatic arthritis, which also kind of reinforces that probably getting people exercising was a good thing. If you suspect they might be dealing with this. And as far as diet goes, there was one pretty well designed double blinded study that found that weight loss seemed to be helpful for affecting joint disease activity for people with psoriatic arthritis, but they tried antioxidants, omega three fatty acids, to try to get an anti inflammatory effect. And that did not seem to work as well. But for people who have obesity along with psoriatic arthritis, weight loss can also be an effective strategy. So that’s that piece. And I think it’s kind of a nice just educational overview of psoriatic arthritis.
Ross Eckstein 7:39
This is a just a simple resource that you can give to people with spine pain, specifically, low back pain is kind of what I focused in on with this. But it talks about some just basic recommendations for how you can change your sleeping position if you’re a back sleeper, side sleeper, stomach sleeper, for different types of pain, you know, if you’re have pain with a lot of flexion, if you’re a back sleeper, talks about how laying with your legs flat might be helpful to put you into some of that natural extension, making sure you don’t use too thick of a neck pillow that’s that can put some tension on your nervous system talks about if your side sleeper to try not to bring your knees up too close to the stomach and that keeping them a little straighter might be helpful. And then it talks about stomach sleeping in general is probably one of the more comfortable positions for people who have pain with flexion. But that if you there’s comorbid neck pain, you have to be careful with that. Because that can sometimes be uncomfortable for people with neck pain. And then it goes into pain with extension that talks about putting your legs up on a couple pillows to flatten out the back if you’re a back sleeper. And then how kind of the opposite, you might pull your knees up a little bit. If you sleep on your side to wreck maybe flex the back a little bit more while you’re sleeping. And then it talks about if you’re a stomach sleeper, how putting some pillows under the stomach to kind of keep the back from extending might be helpful and how using a firmer bed can be helpful so that your stomach isn’t sinking into the bed and putting you into extension. And then it talks about pain with side bending and how there might be some experimentation. If you’re a side sleeper to kind of see what works best is there might be a little bit of side bending with venous side sleeping and then talks about how being on your back might be the preferred position because you won’t be side bending as much with that. And then it talks about stomach sleeping and how you might need to experiment if you do keep one leg up to the side a little bit when you’re on your stomach to try to find which way doesn’t put you into that side that provoking side bent position. And then for all movement hurts, that just gives you some recommendations for just trying to kind of keep the spine and more of a neutral position and give some recommendations for that. And then there’s a also a piece there for if there’s neck pain, talking about positioning with a pillow just to make sure that you’re not side bending too far towards the mattress if you’re have a too flat of a pillow or away from the mattress if it’s too thick of a pillow.
Ross Eckstein 10:44
Hey, Shweta, I think your mic is off.
Shweta Subramani 10:46
Can you hear me now?
Ross Eckstein 10:48
Yeah.
Shweta Subramani 10:50
I was saying that, I think that this is a very neat little handout for patients to look at to really get that visual cue, like if they are, you know, in pain with whatever position then they know exactly what to do, because it’s broken down very well into like sections and like, based on okay, like, if you are a back sleeper with this, and then you know, what kind of category do they specifically fall into and that kind of determines and how we can modify their positions or go into those positions or try different positions, depending on like how their pain changes and things like that.
Ross Eckstein 11:24
Yeah, it’s very, very versatile. And I kind of, I liked that a lot of you know, a lot of times when you look up things on the internet, it doesn’t really individualize very much based on what position hurts. And so that’s kind of was my idea with this is trying to find some a little bit more individualized recommendations for sleeping positions.
Shweta Subramani 11:45
Um, would you say like, there’s like a lot of research out there, though, like, which is very specific to something like this?
Ross Eckstein 11:55
That’s a good question. For this piece, I mostly just went off of biomechanical, just kind of common sense, biomechanics. But the only thing I’ve seen, and I didn’t reference this with this piece, so the only thing I’ve seen specifically, is that typically, for low back pain, firmer beds are associated with less back pain. And so that’s something that people can consider. But again, that’s not something I’ve referenced here. And I don’t have the exact study off, you know, off the top of my head. But I’d say that that’s maybe the one thing I have seen in research is that maybe a firmer bed is helpful if there’s back pain.
Shweta Subramani 12:33
OK. Cool. Thanks. Moving on, our next resource that we have today is the carpal anatomy and diagnostic resource for clinicians and Ross wrote this piece again, so I’ll have Ross talk about it.
Ross Eckstein 12:50
Yeah, so this one is, very, there’s a lot of information with this one. So I’ll try to move through it as efficiently as I can. So, the idea with this is it’s designed for clinicians, and it kind of goes through all the different carpal bones, and you know, how they’re diagnosed. And, you know, it goes into clinical exam a little bit. And then I did talk about imaging, I know that that’s not something that we’re typically doing frequently as PT’s, but it can be good to have that knowledge or at least have something to reference to if you have a direct access patient, and you want to call their primary care provider and ask them if they can be evaluated, just having that knowledge in your, in the back of your mind, maybe would be good. But typically, these are managed by orthopedic physicians. And so this isn’t designed to be something where you’re going to take over for them, it’s more of just some things to keep you aware, both for splint times, and kind of what to expect if someone has one of these carpal fractures or kind of what to keep in mind if you want to maybe refer out somebody who has traumatic wrist pain. So, the first first it talks about the scaphoid and the scaphoid is the most it’s in order by what’s the most common. The scaphoid makes up about two thirds of all wrist fractures and it’s typically young males and the mechanism of injury is typically a fallen outstretched hand. There are actually some it’s of all of these has the most clinical data for clinical tests to kind of rule out these fractures. The there’s three main tests that have been studied. One is scaphoid tenderness so that kind of outlines where to push for that with the snuffbox and then the tubercle on the bowler side, and then talks about the thumb compression test, which is the weakest of the three tests and the text is a little small for me to read, but it has data there as far as sensitivity and specificity for those in general, they’re better screening tools, there’s higher sensitivity than specificity for those. So, you can’t diagnose the scaphoid fracture, but it can lead you away from it a little bit if some of those are negative. It talks about imaging, so typically, x- rays are the first line imaging modality for scaphoid fractures. And typically, historically, the standard of care is to do a follow up x- ray, if they’re negative, you do a follow up x- ray in six weeks or so and see if it’s positive, then because the sensitivity goes up a little bit, I think that the sensitivity at six weeks is like 70%, which is still not great. And so the authors of this, there’s kind of an expert panel of, I think they’re orthopedic physicians who are discussing some of the newer research and they were saying that really, if radiographs are negative, and you suspect a scaphoid, fracture, you’re better off just going with the MRI, because the sensitivity is like 99%, or something like that, it’s very high. Again, I can’t really see the text very well on that, but and then CT scans can be used if you do detect a fracture on x- ray and then you want to find out more information about the fracture, so. And then treatment can vary a lot depending on the location of the fracture, and whether it’s displaced or not. So splint times can vary from four weeks onward to a very long time. So typically, the distal pole of the scaphoid has better blood supply. So, if you have a non displaced distal fracture, then that might need to only be splinted for a month. Whereas, if it’s a proximal pole fracture, where the blood supply is not very good, then that can, need to be splinted for much longer, especially if there’s displacement. So, then the triquetrum is the second most common, I think it was around 18%, something like that. And the data is not very good for accuracy palpating the triquetrum, even experienced orthopedic physicians had pretty poor reliability with palpation for that one. But, it does talk about how you can try to palpate that and then goes into imaging. And typically lateral view X rays are the first line for that. And I can’t remember for sure, but I believe MRI might have been the best confirmation test for that one. Again, I can’t see it very well, but it goes into that a little bit. And then it discusses different treatments, which can range from short- term splinting to ORIF, depending on how severe the fracture is. Trapezium fractures is our third, there’s a little bit better you can do. I think that at this point, the prevalence has really dropped, I believe it’s like 4% or something. So trapezium fractures are very rare. And from here on out, they’re all very rare so, but for trapezium fractures, you can see more pain with movement of the thumb. And so you can provoke that a little bit more easily compared to some of the other ones. So, from a clinical examination standpoint, that can be helpful. And then it goes into your imaging, and different treatments, which again, for all of these really varies, and that’s kind of determined by the orthopedic doctor. Lunate and for the lunate, an MRI is kind of your best best test probably because, lunate injuries are commonly associated with ligamentous problems around around the the bone. And so, MRI will show those the best and clinical tests, there are some clinical tests, there’s a scaphoid shift test, which I talked about a little bit in there, which is where you come into this position and you push on the scaphoid and you look for a clunk. But, I don’t know if there’s really great data for that one. But, that is one that’s historically used for lunate problems. Capitate is, usually from what I remember, I think that one is usually picked up on x-rays, because they’re usually fairly significant injuries, there’s usually significant trauma associated with those. Hamate fractures can vary, you can have hook of the hamate fractures, which the clinical test for that is ulnar deviation, and then resisting your fourth and fifth digit, and then looking for reproduction to pain at the hook of the hamate because you’re wrapping the tendons around the hamate and then seeing if pulling the tendon against the hamate hurts. And that’s kind of the clinical test you can use for that. Again, I don’t know if there’s a lot of great data for that one because it’s a very rare fracture. And then pisiform again, I don’t know if there’s much data for that, it is very rare, at this point we are down to like 1%. And I think at the trapezoid it was like 0.5% ,so there’s very, very little evidence really in the best way to diagnose those but it does outline you know, kind of splint times and mechanism of injury and what to expect with those.
Ross Eckstein 20:16
Sorry, Shweta your mic is off again.
Shweta Subramani 20:21
My apologies. That still looks pretty detailed. Like even though like you tried to be as concise as possible with that, like, just the handout is very detailed in terms of like each of the bones. And I think that that’s, that’s very, very, very resourceful.
Ross Eckstein 20:41
Thank you.
Shweta Subramani 20:42
Cool. All right, moving on. So since some of our resources, have articles tied to them, like in research, we do share that as part of our resources too. And Ross had one such article, which was the diagnostic accuracy of history, taking physical examination, and imaging for phalangeal, metacarpal, and carpal fractures: a systematic review update in 2020. Ross, can you tell us a little bit more about this?
Ross Eckstein 21:13
Yeah, I think the bottom line from this study is that for physical exam, especially, we don’t have a lot of great data showing that you can diagnose definitively, that you can diagnose a fracture in the hand or wrist with physical exam. And so, I think the takeaway for us clinicians or occupational therapists or physical therapists is that when in doubt, refer out. So, the imaging does improve accuracy. And I think in general, they’ve recommended at least radiographs to improve accuracy combined with your clinical test. But even then, imaging tests were also only moderately accurate in that hospital settings for the definitive diagnosis. And so, something to keep in mind that these are very challenging and not straightforward, typically, and that you probably should err on the side of caution when you’re dealing with these.
Shweta Subramani 22:13
Ross, when we’re talking about imaging here, was it specific just to like radiographs? or?
Ross Eckstein 22:27
Yeah, that’s a good question.
Shweta Subramani 22:28
Are they talking about MRI CT as well, because, you know, like how you just talked about in your resource about MRI having a little like, obviously, more sensitivity and specificity compared to like an x-ray.
Ross Eckstein 22:43
Yeah, that’s a good question. And they did dive into that a little bit more individually. And it does vary a lot. So yeah, MRI is much better. And I think that because radiographs are kind of cheaper, and they’re usually more readily available and faster, that’s usually what’s used a lot. And so those radiographs definitely have their limitations with picking up these fractures. And I have some personal experience with this one time, I was worried about, I was doing dips, and I jumped up and I push my hand on something really quickly. And I had pain right over the hook of my hamate and I wanted to make sure I didn’t have a fracture there. And so, I went in for x- rays, and I went into an orthopedic office and I asked for x- rays. And, they did lateral view and PA view and said they didn’t see fractures and sent me home. And, I was thinking how do you see the hook of the hamate with these and I did some research and found that those, the sensitivity of those two types of x- rays is only like 20% or something for hook of the hamate fracture. And so, you need like a carpal tunnel view and you need a supinated view and even with those the sensitivity of a radiograph is only like 80% or something. So, it’s something that you have to kind of keep in mind that there are limitations with radiographs with carpal fractures for sure. And I think that that was something they definitely hammered on in the in that article.
Shweta Subramani 24:12
Yeah, I think like I’m glad you brought up a personal experience because coincidentally, like I had a personal experience and plus I had another like one of my patients today mentioned something on similar lines where she told me that you know, they were not able to catch a hairline fracture in her femur on a radiograph but they were able to catch it on an MRI.
Ross Eckstein 24:37
Yeah.
Shweta Subramani 24:38
So, I was like I mean from the looks of it, it seems like it’s not just restricted to like smaller structures and bones, but even in like bigger bones. I haven’t looked at research as far as you know, like, bigger areas and bigger bones are concerned but it’s I’m guessing it’s probably possible that MRI might still catch things there, which x- rays might not.
Ross Eckstein 25:02
Yeah, that’s a good point, it seems like I’ve seen patients with similar stories as well. I had one with a femoral condyle fracture that was missed with radiograph and picked up with MRI. And so yeah, I think that, in general, you have to be careful. And then of course, there’s also the experience and expertise of the person reading the radiograph too, you know, on top of, on top of everything else, and then acute radiographs are less accurate than radiographs that are taken later. And so there’s a lot of nuance to that. And so, yeah, there’s a lot to consider for sure.
Shweta Subramani 25:35
That’s true. In your experience, did you did you find out if you did, in fact, have a fracture? or you did not?
Ross Eckstein 25:42
I, actually, I don’t know if they’re very happy with me, but I called them back. And I said, I want to come back in for these two views. And they did the views. And at this point, the, the gentleman that I saw was, I think a little defensive and, you know, was saying, “Well, you know, I, I’m not sure, but maybe just maybe just wear a wrist splint for six weeks to be sure”. And so that’s what I did. But, but so I’m not completely sure, because I don’t I’m not an expert in reading them either as a PT, you know, but I suspect that I might have had something going on there. Yeah.
Shweta Subramani 26:14
Because, I feel like, I mean, it’s not just these imaging, like different kinds of imaging, whatever the like CT, MRI, x- rays. It’s also like how your symptoms are correlating with that, right? Like, I had a situation where, like, a car’s rear wheel kind of ran over my toes. And, I was worried too, that I had a crush injury or whatever, I had them get an x ray and like my big toe looked a little swollen, and it felt like that too. But then, they didn’t really see any break anywhere else. And at that time, I didn’t really think about things like okay, I should probably have gotten an MRI to make sure there wasn’t a break, but then the swelling in the big toe, which did, they did see on the x-ray was something that I did have. And I like I had symptoms for that. And that gradually resolved. So it was like, at a point where I felt like okay, if my symptoms are not correlating, then maybe I don’t need more imaging.
Ross Eckstein 27:12
Great. Yeah, that’s a good point, for sure.
Shweta Subramani 27:17
Cool, well, not to get too carried away with that. I guess we’ll move on to our next resource. So, our next resource today is, what is Huntington’s disease. And this resource was written by Troy. So I will let Troy talk about it. Troy, can you please tell us a little bit more about this?
Troy Adam 27:37
Yeah, sure. So, Huntington’s Disease is a rare neurologic disorder that ultimately affects portions of the basal ganglia. So often, when we hear about that the first thing that clinicians think of is Parkinson’s, right, that’s one of the more common diagnoses that also affects areas of the basal ganglia. In this case, we see symptoms that in some ways are similar to you know, kind of these motor coordination and movement. diseases. With this, the defining feature of Huntington’s disease is is, is chorea, which is a form of, kind of movement spasm, that is pretty severe in nature. I guess, you know, even maybe, even before I jump into this resource a little bit, this is this is a diagnosis that is that is pretty severe and significant. It ultimately ends ends in the patient dying. So as a caveat with this, we need to be really thoughtful, I think, as clinicians when we approach this handout, right, so this isn’t something that I’m going to necessarily, you know, I’ve got a patient that comes in that’s referred from neurology, with a diagnosis of Huntington’s disease, and this isn’t going to be the resource that I pull out, and I’m like, Oh, look, I’m this really well prepared clinician. And, you know, let me give you all these resources on Huntington’s disease, because, you know, there’s some things in this document that are hard to that are hard to kind of accept and swallow. So, but so I guess that being said, what the disease process is, is it’s a genetic disorder. So, it doesn’t happen as often. The incidence is down compared to, you know, years ago because of the fact that there’s genetic testing that’s available. So, if you if you’re a carrier of this and you have this genetic mutation, there’s there’s potential that you would, you would pass this along. So to any offspring that you have the average onset of symptoms is folks in their mid 40s. And they develop these kinds of facial twitches. Often what begins. So this can be kind of like odd smiles or frowns, they’re pretty dramatic in nature, they’re not very subtle sticking out of the tongue. That’s a common symptom associated with Huntington’s disease as well. As the disease progresses, it begins to affect more, yeah, more extremities, things other than the face. So, arm movements, leg movements, trunk movements, obviously, then, because of that, mobility becomes more and more challenging. So, in later stages of the disease, we might work on getting patients adequately supported, and in a wheelchair, you know, maybe, maybe there’s custom seating systems that are needed to make sure that these choreatic movements don’t cause the patient to fall out of their chair or something along those lines. So, I’m thinking about that about assistive devices, maybe as gait begins to deteriorate. Ultimately, this, this disease will continue to progress. So, your goals are really about maintaining safety, and mobility, to the best of the ability in in that moment. So, being very forward and upfront, I think with your patients about what your goals are about, what can we do to best prepare for one year from now, or things like that, and kind of having those conversations, because this is a patient also that really would would likely benefit from therapeutic oversight, probably, you know, for the entirety of their diagnosis. So this isn’t, you know, this isn’t a standard one or two plans of care, I’m probably going to see this patient until they potentially have to transition to an assisted living facility or some sort of long term care if caregiving becomes more, more challenging later on. So, you know, at the bottom of this resource, we talk a little bit about specific ways to or the ways that different disciplines might interact with someone with Huntington’s disease. So, it gives a couple of examples of things that you might be concerned about, or write goals towards, and have objectives for whether you’re a speech therapist or an occupational therapist or physical therapist. The goal with that is really, you know, with Huntington’s disease being relatively relatively rare, I wanted to make this resource something that we felt like all disciplines could use, not just physical therapy, because ultimately, speech therapy and occupational therapy are going to be a huge part of, of habilitation in, in these patients. Especially speech therapy, in later, yeah, kind of later disease process. So.
Shweta Subramani 33:15
Are you guys able to hear me?
Troy Adam 33:16
Yeah.
Ross Eckstein 33:17
yeah.
Shweta Subramani 33:18
So, Troy, I haven’t had much experience with like working with patients with Huntington’s. But then like, you know, from your handout, maybe it’s making more sense. I would assume that, you know, they would be in like transitioning to skilled nursing, long term care,probably palliative and hospice care at some point too?
Troy Adam 33:40
Yeah, absolutely. At some point in time, you know, that. That is very, very likely, I guess. The, I think the, you know, the prognosis for someone, at least in North America, I want to say you kind of based on when the average person is is this is detected, I think life expectancy is maybe around 15 years, if I remember, right. So it’s not, you know, it’s not immediate, but you’ll see continued kind of decline. I guess one of the things that we didn’t mention, you know, I speak as a physical therapist primarily about the physical limitations, but this is going to affect cognitive function as well. So that’s, that’s another, you know, when I kind of gave us our disclaimer at the beginning of, hey, this, this is something that you want to ease into in terms of discussion with your patients, that can be obviously a whole another realm of challenging conversations. We’re talking about declining kinds of cognitive status for folks with this diagnosis.
Shweta Subramani 34:50
I think like the goals also will get like more and more specific depending upon like, what stage of progression they are in.
Troy Adam 34:58
Yes, absolutely. Absolutely. Yeah, so if you’re seeing me right out of the gates, you know, it’s gonna be a lot more motor coordination type tasks. And, I think safety and and forward thinking. Preparation, I guess is probably the most important. But, once you get later on, you know, safety is, it’s different, right? Like I said, it’s maybe custom wheelchair seating to make sure that you can, you don’t fall out of your chair or something like that, as opposed to how do we navigate with bilateral trekking poles or something like that over over terrain. So yeah, yep.
Shweta Subramani 35:37
No, absolutely. Like, I like that you mentioned like this whole section about how therapy is optimizing the quality of life, because I feel like, you know, based on all this information, obviously, they need to be educated early on as to what the prognosis of the disease is and we are not really working towards, like, trying to get to a prior level, but more like maintaining the quality of life at each stage and each progression that they’re having.
Troy Adam 36:05
Yeah, yeah, totally. And I think that’s, that’s really important. And, if you’re, if you’re not a physical therapist that treats a lot of folks with neurodegenerative conditions, I think this can be a hard thing to appreciate the fact that hey, guess what, my goals aren’t about getting you back to, like you said, your prior level, but but rather, kind of preparing and making things as optimal as we can right now, because this is gonna, this is going to get worse. So yeah, you know, you have to, you really have to balance therapeutic goals with patient trust and patient understanding. It’s a delicate, yeah, it’s a delicate situation, for sure, for sure.
Shweta Subramani 36:52
Cool. Thank you for talking about this. Okay, so moving on to our next resource. This resource was created by Troy again, and this is should I use hot or cold? Troy can you tell us a little bit about this?
Troy Adam 37:10
Yeah, this one is totally different than the last one we talked about right? So this is the kind of classic oh, I don’t know, elevator question that you get passing by type thing. You know, all, you know, all have buddies or, or even physicians that will be like, you know, hey, I’m having this conversation with, you know, with my friend, we can’t remember like, should we be using hot therapy or cold therapy after this. So, so this really is designed as a patient resource more than anything else that says, that ultimately tells you, there’s a couple, there’s a couple things that you should only use ice, or you should only use heat, but for the most part, there’s a lot of carryover of this modality to a variety of different kinds of injuries or ailments. So hot and cold therapy, I would say right now in at least in the United States, I think modalities in general, and I’ve mentioned this in the past have really kind of swung to one end of the spectrum in terms of probably being a little devalued or less valued than, than they maybe were in let’s say, you know, the 80s, or when we were using hydrocollators all the time, or, or things like that. We don’t we don’t see that quite as often. But, but guess what hot and cold, it’s been around for a long time. We have been treating, treating patients with these types of things for for a very, very long time. So, you know, take this as you will, in terms of how you incorporate it into your practice. But, it outlines yeah, just this hot, hot therapies what types of things they are. So, you know, it’s not complicated hot packs, hot tubs, infrared lamps, paraffin baths, and as well as cold therapies, what types there are how, you know, how we would, how we would cool somebody’s tissues down. And, then it talks about what it does when we heat up tissues or cool them, as well as indications for that. So, this one is unique, and you have to be able to kind of navigate your way through the directions in this sheet. So, there’s a color coordinated, kind of asterix, that are associated with specific conditions, and whether or not cold heat or either are appropriate. So, for things like I mean, really, the big one that I think a lot of people would understand is an acute injury, right? an acute injury is going to be something that we are not going to put heat on right so that’s not that’s not appropriate. If someone is actively hemorrhaging, you know, we are not going to we’re not going to put heat on that and increase blood flow right? So, but, it If someone has, let’s say, yeah, so this cellular trauma, right? meaning a wound or an injury, we’re gonna, we’re gonna put cold on that if they have a tendinopathy, we’re gonna put cold on that. Bursitis, we’re gonna put cold on that, versus abnormal muscle tone, or trigger points or pain, those types of things can be used with either hot or cold therapy. So at the end of this, it does mention contraindications. Some of those are also kind of asterix with, with whether or not hot or cold is, is appropriate or inappropriate in this case. So, things you know, I felt like if we were going to give this to a patient that was asking about “hey you know, I’m hurting or whatnot, and I have a hot pack, should I use it, or rice bags or put it in the microwave? or should I put it in the freezer?” I wanted to at least give our patients some understanding of contraindications so that we can hand this to them, and feel like we did our due diligence in terms of making sure that they were gonna be safe to be able to perform some of these things too. So, ultimately, a simple but hopefully effective resource for yeah, for your patients.
Shweta Subramani 41:19
Thank you, Troy. And, Troy did give us insights from an article that was related to this resource. So, I’m going to have him talk about the article. So, that is our next resource, which is heat and cold therapy reduced pain in patients with delayed onset muscle soreness, a systematic review and meta analysis of 32 randomized controlled trials. Troy, can you tell us a little bit about this?
Troy Adam 41:47
Sure. Yeah. There’s there’s ultimately this study is is yeah, trying to kind of determine what I was talking about earlier with hot and cold therapy. What’s what’s better? What do we what do we want to use it for? This is specifically looking at DOMS, right? which is this delayed onset muscle soreness. This is what happens is the phenomenon that happens after you do an excessively hard workout for you and you experience kind of extreme muscle soreness that progresses, you know, probably for the first 24 hours, and then and then maybe gets worse, or continues on for several days. So, anytime anybody can experience this after they significantly increase their workload. So, this doesn’t have to be just for our elite athletes, we can see this in other individuals as well. The researchers here, really reviewed a lot of literature, there’s, there is a lot of literature on hot and cold therapies. Unfortunately, a lot of it is not very good. It’s not very well controlled, or done in a very systematic way. The hope would, was of this, was to collect, collect studies, grade those studies on how how well they were able to perform their stated goals. In this case, they looked at a variety of randomized controlled trials that I think included a little bit over 1000 different subjects of these. For the most part that the articles that were included, had either hot or cold therapy is provided within one hour post workout. And, really what they found was there, there wasn’t a ton of difference between hot or cold post workout. They did find that there’s maybe some reduction in pain. So, again, it’s subjective, a subjective thing. But, but regardless, on a visual analog scale, there was some reduction in pain within that first 24 hours. There was reduction for both groups, both hot and cold groups. But, beyond that, there wasn’t any significant difference after 24 hours in terms of decreasing the pain. So, you know, where this is probably most helpful is going to be for someone that has to perform again, within that period of time. So, you know, my, the classic example might be, you know, the, the elite power lifter that is in maybe not a power lifter, let’s say CrossFit or something along those lines, where you have one event, and then guess what you got another event four hours from now, that might be a good time where where there is some evidence to suggest you might have some decreased pain associated with this. So, you got to do it right away or right after within that first hour is is what they found. And, then really hot or cold would, would be would be appropriate, based on on what they found. So, in my opinion, I would do whatever, whatever feels best and most conducive for for that individual. Yeah.
Shweta Subramani 45:22
Perfect. Thank you, Troy. This was actually interesting. And this being more recent, I’m glad that they were able to like, you know, at least they haven’t told for sure that one has greater benefit compared to the other. But I’m glad that both are useful. Because, honestly, before this was mentioned, I was under the impression that it was always like, heat not so much cold. Glad that we were able to clarify that we can use cold as well. And again, like the timeline of doing it an hour post activity within that one hour, like, I’m glad I got to know about that.
Troy Adam 45:58
Yeah, it’s, it’s, it’s, I mean, ultimately, it’s a hard thing to study, because you can’t, you know, to biopsy these tissues or something like that, you know, these temperature changes are already going to happen. So, it’s a tough thing to study. And there’s, there’s a lot of odd phenomenon around hot and cold therapies, too, right? If you cool a tissue down for an extended period of time, we actually see an influx in tissue temperature later on, because your body says, “Oh, hey, guess what, this is cooling down too fast, put as much energy and blood here as we can to warm this back up”. And, before you see it starts to cool again. So, you know, it’s, it’s, it’s a hard thing to, yeah, it’s a hard thing to study or a hard thing to prove. And, that’s probably why there is not a lot of great evidence on it. But, again, as I mentioned earlier, you know, people have been using thermotherapies of one sort or another for for a very long time for for for healing. So I think it’s, I think it’s something to at least consider and value to some degree. So.
Shweta Subramani 47:05
Yeah, I mean, I was under the. So, like with delayed onset of muscle soreness, it lasts anywhere between 24 to 72 hours, post, you know, doing that, an activity of that intensity, which you’re not used to. So, I was under the impression that any time between that timeframe, that it really intensifies compared to when you know, it started they are okay to use heat. I did not know that it was restricted just for an hour post.
Troy Adam 47:34
Yeah, and you know, so I guess I can’t say if that is, if that’s needed or not, because ultimately, what they did is they looked at only studies that provided this intervention within one hour. So, beyond that, I can’t say yes or no, right? But, what I can say is that this is what they found, based on if this intervention is provided within one hour. If we were to look back at that other resource, there’s a lot of reports of analgesic effects from both hot and cold in the moment, at the very least, you know, regardless of the pain is acute or chronic, or, or whatnot. So, there’s some pain modulation that can can occur for some individuals with each of those. So, so to say that it’s not worth doing after beyond that. We can’t make that conclusion. Yeah.
Shweta Subramani 48:27
No, that makes sense. Absolutely. So, moving on, since we end all of our shows with a case study, we’re gonna be talking about today’s case study. And, these are a great opportunity for us to use the resources in our access pass library and apply them to these cases and discuss these cases from different perspectives. Okay, so today’s case study is a 40 year old woman with right cervical radiculopathy, lives with her spouse, works as a stock trader, and she has to spend long working hours on her computer. She’s been experiencing some worsening pain recently in her neck and it has been limiting her neck mobility and her ability to work. She wants to get rid of her pain and get back to doing things like she was doing before. So, the resource that I recommended for this and again, this was kind of loosely based on one of my patients. The resource that I recommended for this one was the associated dermatomes, reflexes and parasthesias for cervical nerve roots. Basically, I felt like this resource helped me like demonstrate like, you know, like educate the patient more specifically, like what areas would really be affected and where she would really feel the pain depending on what is involved as far as her neck is concerned. Because, this patient found it really hard to like, understand and like, till she was able to get like a, just a good visual view of things as to like what is exactly going on in her spine and how that is impacting her neck, her shoulder, all the way up to her arms. So, I felt like this being a very concise, colorful resource, very, like there is grouping, each level based on like the dermatome location, the associated muscles, the reflexes, and then if they would experience any kind of parasthesias or not, like it was very helpful for the patient to understand not just in terms of like the pictures, but also like, okay, maybe my muscles are involved. And, if I’m feeling numbness, at what level what is expected. So, I think this is a very great resource to like, educate patients, especially the ones that are visual learners and find it kind of harder to understand when you speak in technical terms. So they’re able to like visually see what’s going on. And, then that kind of helps them not just understand their symptoms, but it kind of sets realistic expectation as to like how they can progress in therapy. So moving on, the resource that Troy recommended for this.
Troy Adam 51:28
Yeah, great. So, this one is, this one is just instructions for acute neck pain. It is it’s a specific, It’s a very specific kind of protocol that is, if, if I remember right, it’s kind of kind of a McKenzie type method. So, McKenzie is, yeah, a physio that, yeah, that has been around for a little while and has developed specific kind of movement, movement patterns. So, this resource just goes through potential, yeah, kind of potential options and progressions for someone that is experiencing acute neck pain. This is one that I would say, is really meant for yeah, for the patient as a handout that I would think of more as like a, maybe this isn’t our primary concern, right? Because, because there’s not a lot of assessment necessarily, that I’m doing with this, this is more for the patient. So, it’s, it’s a tool for someone that, you know, maybe is experiencing pain in the past and has had success with this type of method or something along those lines. But it’s a nice, specific, detailed outline way to, it’s written in a lay perspective, for someone to be able to kind of pick up and navigate their way through some progressions of decreasing their neck pain. Yeah.
Shweta Subramani 52:58
Troy, I will let talk about the other resource that you recommended for this particular case.
Troy Adam 53:08
Yeah. Perfect. I know, I couldn’t help myself, I was like, oh, man, this one’s for this stock trader right. So, this is a nice handout for someone that yeah, that’s working at a desk space. And, if they feel like their pain is is, is a result to some degree of their workspace ergonomics, this is a nice way that, you know, doesn’t necessarily require like a PT to come into the workplace to set it up. But, you know, if you’re, if you work a job that’s repetitive in nature, sometimes they will have that as an option. But, let’s say you don’t, or you’re working for yourself, or you’re at a company that’s not quite big enough to be able to satisfy those things. So, this is a way that you can help to manage your own posture, I guess, and ergonomics when you’re, when you’re working at a desk. So, it’s got a checklist of kind of things to go through and look at that yeah, are about table height, monitor height, chair heights, angles of the chair, feet placement, all of that. So, a nice resource for a patient as well, that’s, that’s trying to set up their their space for for comfort.
Shweta Subramani 54:24
Perfect, so the next resource is the one that Ross recommended for this particular case and that was the DN-4 for evaluating neuropathic pain: interpretations and implications for practice.
Ross Eckstein 54:37
Yeah, this piece is definitely designed for clinicians. The DN-4 is probably my favorite outcome for evaluate or favorite outcome measure for evaluating neuropathic pain. What I like about it is, it has very high sensitivity compared to a lot of other tools like the LANSS, and it takes about one minute to do and it’s integrated pretty seamlessly into your own history and your clinical examination. And so, it’s a pretty nice tool for being able to rule out neuropathic pain. So, we know that a lot of people can have referred pain from the neck, and it might be discogenic referred pain, which isn’t really a neuropathic issue. It can be radicular referred pain, which is or could be true radiculopathy, where you have your myotome, dermatome, reflex loss as well. So, with this tool, it can be helpful to determine if they someone has neuropathic pain. The reason why we care about that, there is a, the first section kind of goes into what you can do with that information. So, we know that nociceptive predominant pain, there was a pretty good meta analysis in the European Journal of pain, I think it was in 2021, where they looked at conditions that were affected by, that were more nociceptive predominant pain compared to nociplastic predominant pain, and nociplastic predominant pain is where it’s essentially the concept of neuroplasticity and then applying that to pain, where neural pathways that are used a lot are strengthened. And, with nociplastic pain, things that really shouldn’t be painful anymore, like having your skin brushed, become very painful and you get sensitization of the nervous system, essentially. And so, there is some evidence that people who have persistent neuropathic pain are more likely to develop nociplastic pain than people who have persistent nociceptive pain, though, nociceptive pain can cause that it’s just less likely. And, the evidence seems to suggest that higher intensity exercise, you get a really nice analgesic response from that, which can kind of be helpful. So, as an example, there’s another study where essentially they had people with nociceptive, back pain do high intensity cycling or low intensity cycling, and the high intensity cycling was better for reducing pain. But, it’s kind of the opposite is true when you’re dealing with issues like persistent neuropathic pain that caused those nociplastic changes, where actually a lower intensity approach is more appropriate because a lot of the natural indwelling inhibitory processes that we normally have with exercise that can inhibit pain, they’re not as functional with some of these other types of pain. So, it can be good to determine whether someone’s actually true dealing with true neuropathic pain versus like discogenic nociceptive referred pain. So, the tool itself is pretty easy to use. First, you do a couple interview questions, you ask if they have burning painful cold sensations or electric shocks, and then you ask about tingling pins and needles numbness or itching. And then, you for the patient examination, you check for touch hypoesthesia, and then pricking hypoesthesia, and then you brush, you take some cotton or something, you brush it over the painful area and see if they interpret that as being painful. You get one point for every yes, and a cut off of over four suggests that they have neuropathic pain with pretty good sensitivity and specificity. And so, like I said, it takes about one minute to do and it’s, it’s nice, because a lot of our other outcome measures, you know, they can, there’s tons of outcome measures we’d love to use, but it’s hard too because you don’t want the patient to be in there for an hour doing paperwork. And so, I really liked this. It’s kind of a simple, easy to apply tool to evaluate that.
Ross Eckstein 55:02
Oh, thanks, Ross. I didn’t even know about this questionnaire. So, maybe I’ll give it a try and see how effective it is with my patients.
Ross Eckstein 59:05
Yeah, it’s something I actually kind of stumbled on in the research. And, it’s not something I was very familiar with. I think it’s more commonly used in France, actually, I think that that’s where it was developed. And so, but I think it’s very valuable. And, I like that it’s very efficient and quick, so.
Shweta Subramani 59:24
Awesome. Okay, so before we wrap up, I do want to mention some of our interdisciplinary resources that were added to our library, that maybe you all might be interested in. Our OT team created resources, some resources. There was one called overstimulation after brain injury, which basically talks about like, what kind of sensory overload can an individual experience after brain injury and what strategies can they use to cope for that overstimulation. What are some of the signs that you can use to identify like that they are having the side effect after a brain injury and what strategies you can use for this. Another great resource that our OT team created was about the different rehab settings. This would be a good understanding for someone who is just beginning to practice as a clinical therapist and they want to have a better understanding of like how the whole transition works from like a hospital all the way up to outpatient, so then they can look at our resource and understand different rehab settings and like, at what level do you send patients to which setting and then what setting would be appropriate. It just helps new grad therapists understand and like and make good discharge decisions. Another resource that was created this was by our SLP team. This was for incentive spirometer. And this gives us a good view of like the different how you can use the spirometer and then at different lung capacities, what can you expect, what do you need to look for, and then how this can be really effectively used in clinical practice. Also, I forgot to mention our OT team created another great resource called subacromial trauma. So basically, this talks about what you can do when you get patients with subacromial trauma and what kind of precautions you need to follow and then, how best can you refer these patients out. So, if you do get a chance, feel free to check out these awesome resources in our access pass library. I just wanted to say, thank you so much for watching our recording or listening to our podcast. Please feel free to check our access pass library and use our resources, and we hope you find them helpful.