MSK research and Rx

Question 1

What is first on the problem list for James and explain why?

Answer 1

Pain, especially in side flexion and rotation to the left which is affecting his golf and his driving, affecting mood (frustration).

Question 2

How is stiffness a problem for James?

Answer 2

Limited range of motion is impairing ADL’s, his exercise regime and driving so this becomes dangerous and de-motivating

Question 3

How is neck tension and muscular dull ache a problem?

Answer 3

This could show muscular tension which could increase the amount of migraines he is having and mean he has to take time off work

Question 4

How is forward head posture a problem for James?

Answer 4

This guarding position will increase the strain on the back of neck and up James stress levels and mood due to migraines

Question 5

How is sleep disturbance a problem for James?

Answer 5

The stiffness and headaches affecting sleep making him more frustrated

Question 6

What barriers to James’s recovery are there?

Answer 6

Uncertainty on his condition, fear avoidance, scepticle for physio, low mood and frustration, working long hours and stressful job, history of migraines, poor posture, difficulty sleeping, mild hypertension, potential money issues with compensation.

Question 7

What ethics/morals should we consider for James?

Answer 7

Respect his autonomy as he’s previously hesistant, SDM after patient education, PCC by tailoring the exercises specific to his golf, principles of beneficience and non-maleficience and justice with follow up.

Question 8

What MDT involvement for James?

Answer 8

Talking therapies to signpost to with stress and anxiety with job, get partner involved, psychologist, occupational health or ergonomist for sorting desk posture, GP for pain medication review if pain continues.

Question 9

What are the NICE guidelines 2023 for physiotherapy and self - care in WAD?

Answer 9

Encourage early return to pre-accident activities, focus on improving function, physio should have a multimodal treatment appproach of ROM, strengthening, stretching and manual therapy.

Question 10

What is NICE 2023 ADVISE on if pain scores aren’t improving in 12 weeks post whiplash?

Answer 10

Consider referring to a pain clinic for a MDT pain management programme, refer to a neck specialist if pain is more than 5/10 and neck disability index (NDI) of 15+/50.

Question 11

How can I explain to James what whiplash is…

Answer 11

The impact of the collision has caused your neck to go into hyperflexion and hyperextension past a range it may usually be comfortable with and the soft tissue structures can become overstretched.

Question 12

Why is the distraction test providing mild relief?

Answer 12

There may be some mild compression on the nerve roots but no radiculopathy due to no arm weakness or pins and needles.

Question 13

What evidence have I got for exercise cervical?

Answer 13

Peterson et al., 2024 (case control study) found WAD pts after following neck-specific exercises targeted at the impairment showed more significant improvements over time in pain, neck disability scores and neck muscle fatigue than a control group of healthy individuals after evaluating neck function using ultrasound.

Question 14

Why am I giving unilateral PA glide on the right side when it’s left neck rotation impaired?

Answer 14

This PAIVM helps by applying force to the facet joints on the right that are restricted to reduce stiffness and increase ROM to address structural and mechanical restrictions.

Question 15

What evidence have I got to back up my unilateral PA glide and the use of a SNAG?

Answer 15

An RCT on manual therapy techniques found significant reductions in pain scores for both SNAGs and mobilisations and improvements in all ROM post-treatment and on follow up (Perez et al., 2014).

Question 16

What is my explanation for why I would do a sustained natural apophyseal glide?

Answer 16

Mulligan proposed that SNAGs are used when there is a positional fault, applying this MWM will elicit a PILL response (pain free, instant and long lasting) as long as not highly irritable.

Question 17

What evidence have I got for mobs grades for James?

Answer 17

Loreto et al., 2024 conducted a RCT and found significant reduction in pain scores for non-mechanical neck pain (no specific structure) compared to a patient education group when working grade 2 for 1 min, then 3 for 1 min and then 2 for another minute and also improve pt satisfaction.

Question 18

What other exercises could i do for James?

Answer 18

Chin tuck to encourage correcting posture, side flexion pushing into hand to strengthen sternocleidomastoid and scalenes and extension with a towel to mimic a snag.

Question 19

Explain why I’d do soft tissue on James?

Answer 19

Massage, soft tissue release and trigger point can be useful for reducing tension in the posterior neck musckes and upper traps as these carry stress from work and may help alleviate neck pain.

Question 20

What can I explain to James for patient education?

Answer 20

Education on whiplash, the prognosis of symptoms start to ease within 2-3months so expect improvements soon, encourage gradual increase in ROM and encourage returning to activity to facilitate recovery.

Question 21

What advise for driving for James?

Answer 21

Would advise him that if possible he avoids driving on motorways as restricted movement will affect checking blind spots and to avoid overall if possible while sudden movements are causing a twinge.

Question 22

What can we do if in 3 months he has still made no improvement?

Answer 22

Reassess him using VAS and NDI to assess the impairments on his ADLs, educate patient that persistent symptoms may not mean any severe damage, check symptoms haven’t worsened to a radiculopathy, may need pharmalogical management, emphasize graded exposure and not avoidance.

Question 23

What adjuncts to physiotherapy could James use?

Answer 23

Continue heat therapy to help manage pain and muscle spasms, continued massage to break down tension, NSAID pain medication and ultrasound over muscular areas to promote blood flow to the area for tissue healing regeneration.

Question 24

What outcome measures can be used for James neck pain?

Answer 24

Neck disability index (scored out of 0-50), VAS, ROM assessment using a goniometer, EQ-5D-3L test helps measure the patients QoL.

Question 25

How does MT work on pain gate and descending inhibition as well as mechanical creep?

Answer 25

It helps target the nociceptive alpha and C fibres to inhibit pain signals being transmitted to the brain. The sustained passive pressure can induce tissue lengthening and hence creep.

Question 26

What is first on the problem list for Rosa?

Answer 26

Pain reaching a 6/10, which is mainly affecting running over 15mins, walking uphill which is affecting her preperation for 10k and lowering her mood.

Question 27

How does glute weakness after Rosa?

Answer 27

The limited strength in hip abduction showing glute medius and minimus weakness, causing mild trendelenburg gait and posture affecting single leg stand and transferring weight into running.

Question 28

How has impaired and antalgic gait affected Rosa?

Answer 28

This may cause compensation and increase pressure/strain on the opposite hip and will affect transference of weight so unable to run with the correct technique.

Question 29

Why might the mild thickening over the greater trochanter be a problem?

Answer 29

This can increase pain by placing increased pressure on the gluteal tendon which could be causing increased pain and disrupted sleep which could affect work social life.

Question 30

How will pain on single leg weight baring activities affect Rosa?

Answer 30

Her job as a primary school teacher requires long periods of standing and changing into trousers so may be affecting ADLs, needing breaks and frustration.

Question 31

What barriers are affecting Rosa's recovery?

Answer 31

She has a 10k race, high BMI of 30 increased strain on weight-baring joints increased risk of OA later in life, frustration, increased anxiety and fear of worsening mental health, suspected hypermobility and recurrent injuries can reduce her joint stability making her more prone to subluxation, uncertain on diagnosis (lack of education).

Question 32

What ethics/morals to consider for Rosa?

Answer 32

Respect Rosa's autonomy and her wishes to continue running, SDM approach, promoting active recovery to work on the principles of beneficience, maintain dignity due to the area, gaining informed consent for any passive treatments and touching.

Question 33

What study for SDM in both?

Answer 33

Thompson et al., 2024 studied the effects of shared decision making in first contact physiotherapy for adults with MSK disorders helped to improve patient satisfaction and treatment adherence.

Question 34

Who can be included in the MDT for Rosa?

Answer 34

Counselling/talking therapies through NHS to help with stress management techniques for her anxiety, GP to hel with the diagnosis of hypermobility and any pain medications/NSAIDs, dietician could help make ammendments of diet to help weight loss, NHS for weight loss advise.

Question 35

What is the NICE guidance 2023 on simple managements of GTPS in over 16s and physiotherapy?

Answer 35

They suggest to advise avoiding activities that worsen the pain e.g. lying on the affected side, offer NSAIDs, information on weight loss and applying ice for 10mins every few hours, strengthen hip abduction and strength and stretch the glute medius and minimus.

Question 36

What is the NICE guidance 2023 on management in over 16s for referral if pain continues with GTPS?

Answer 36

Corticosteroid injections can be considered if pain doesn't go with conservative treatment, refer if any red flags arise to A&E, orthopaedics or secondary care if pain doesn't reduce especially over 3 months for those under 40 as further assessment may require imagery.

Question 37

What is my evidence for standing isometric hip abduction into the wall?

Answer 37

A pilot study by Clifford et al., 2019 found that a combination of isometric and isotonic exercise reduces pain scores and improves VISA-G scores (less disability), the contraction type didn't matter but isometrics may be more relevant when limited in wide range hip abduction.

Question 38

Rosa What is my other research for exercise management approach f?

Answer 38

A review by Grimaldi et al., 2015 proposed that a lack of pelvic control in single leg loading tasks increases stress on glute tendon and ITB hence load and exercise management reducing eccentric load to tendon initially to strengthen the glute medius with posture correction is a plausible approach to rehab.

Question 39

What is my second exercise and why for Rosa?

Answer 39

Banded lateral walks below the knees i.e. ankles to target glute medius more is an isotonic exercise which can be equally as effective and helps improve joint stability in hip and knee with her previous dislocations and her hypermobility.

Question 40

What is my evidence for band placement for Rosa in squat walks?

Answer 40

Cambridge et al., 2012 found distal placement of the band down by the ankles instead of by the knees increase glute medius activation by 15% in the sumo squat walks hence strengthening abduction and external rotation of the hip.

Question 41

What manual therapy technique would I use if she didn't improve and why (using research)?

Answer 41

Look to do a passive hip abduction in grade 3-4 as joint mobilisations can reduce tendon pain and help rehab by the pain gate theory and descending inhibition for tendinopathies shown in a review article by Mavva et al., 2021.

Question 42

What other glute treatment can be done for her?

Answer 42

Soft tissue treatment such as myofascial release or trigger point therapy may be necessary if she has muscular tension to reduce pain but must supplement exercise therapy.

Question 43

What outcome measures can be used for Rosa?

Answer 43

VAS, Single leg stand, handheld dynamomter, re-test oxford grading scale and VISA- G (Victorian institute of sport assessment glute) to assess disability from gluteal tendinopathy.

Question 44

How to explain to Rosa her diagnosis?

Answer 44

It is likely that the running and increased load on your hip is causing pain, inflammation and irritation to the tendon of your gluteal medius and minimus muscle which attaches to your greater trochanter bone on the outside of your hip.

Question 45

How can we educate Rosa on modifiable factors for her gluteal tendinopathy?

Answer 45

Advise her to adopt other forms of CV endurance such as cycling to stay part of the social group or interval running for no more than 5 mins at a time, avoid crossing your legs or lying on the affected side, distribute weight evenly i.e. don't stand with more weight on one leg, place a pillow inbetween legs and listen to your body take breaks.

Question 46

What adjuncts to physiotherapy for Rosa?

Answer 46

Mobilisations, massage, corticosteroid, NSAIDs, ice for temporary pain relief and shockwave.

Question 47

What is the evidence of shockwave therapy for Rosa?

Answer 47

A randomised control trial by Carlisi et al., 2018 found shockwave to reduce greater trochanteric pain in both short term (2) and long term (6 months) and was more effective in ultrasound by releasing kinetic energy to regenerate the tendon.

Question 48

What to do if Rosa doesn't improve in several months time?

Answer 48

Reassess to ensure diagnosis his not been missed, reassure it doesn't mean serious, regress any exercises, understand treatment adherence, try any passive treatments that have not yet been used, address her load activity, refer for investigation by orthopaedics or for imagery, consider corticosteroids despite only short term improvement,