Hi all! Excellent discussion! This patient has been very very interesting. I commonly see reproduction of lower quarter symptoms w/ assessment of the thoracic spine, usually when the PT is just pushing well beyond the end range of the segment tested and moving the lumbar spine, but in this case, reproducing a very specific L/S pattern of symptoms from the mid-thoracic spine with very specific central PAIVM in the M/T spine (with consistent response) was pretty bizarre. I was definitely thinking about T4 syndrome (:\), but even more, about Butler’s discussion about tension points and the presence of a ‘double crush’ influence from the t-spine, especially after the emerging thoracic history.

I appreciate the comments about close reassess of the neurological findings – I don’t think that point can be emphasized enough. The consistent reassess of the neurodynamic testing is also an important barometer. Also, in regards to referral to an MD – If this patient was not already being followed by an MD, I definitely would not wait at all. I would start the process of an MD consult, so, if the signs and symptoms deteriorate, or return, the patient is already on the path to further diagnostic testing and establishing a relationship with someone who can get the ball rolling on ECI, or surgery, if ever indicated. I am careful to not be too dramatic about the suggestion, i.e., avoiding feeding fear, but I think it makes good sense.

A couple more points.

I believe the ECI plus PT was shown to have better outcomes than either alone, but don’t recall the results being ‘great’ (that was just Laura having a positive impact on the patient’s psyche!). We will find that study and post it for further discussion.

Also, it is an important role that we play in monitoring the patient’s neurological status so closely. It is a great thing that we are seeing the patient more frequently and can reach out to the doc if the situation starts to rapidly regress. If not for P.T., 3-4 weeks may go by between reassessment of the + neurological findings.

In addition, the communication and relationship with the MD is important! This guy had an EMG and we are scratching our heads about the neurological status and prognosis and don’t have the EMG results. It is important to call the MD and discuss the case. The MD who performed the EMG may have a perspective that would be very helpful and all the best for the patient if the medical team is in communication. Laura will have more on that.

… If a week or two goes by and you have not discussed a case with an MD who is co-treating a pt. with you, pick up the phone. You will learn a lot, they will learn a lot, and the patient will be receiving better comprehensive care.

As Laura mentioned earlier, this pt. was convincing himself to have surgery because he was anxious to get back to vigorous exercise and was losing patience. The point I try to make is that surgery is not like a fast food pick up..you don’t just drive to the second window and pick up your return to full activity. Many believe this is the case. By starting some more vigorous exercise w/ emphasis on neutral spine/no increase in symptoms/emphasis on strengthening w/o increased vertical load on the spine, Laura was paralleling with his goals/concerns and he was able to move on from the mentality of ‘I need surgery so I can exercise’ (not to mention all of the other benefits to adding the exercise…)