Hi Katie,
Thanks for posting.
I think you address the preconceived notion of needing the “crack” by educating/explaining that manual techniques, including but not limited to manipulation, will be part of his treatment plan. Explaining that manipulation may play a (small) role in his treatment should make him feel that his preferences are being listened to but also help him understand that PT is more than getting your neck cracked.
I think I have a bias that makes me think twice before providing a treatment that a patient has specifically asked for. I think it’s because I want to make sure I feel it’s the right treatment at that moment. So, I try not to let their request or preference weigh as heavily on my decision. I’m not sure this a good thing though. I guess you could argue that I risk losing some patient buy-in if I’m too rigid in my decision making.

Hey Katie,

I agree with Justin that I think the best way to address his focus on manipulation is to educate him that it will be a part of a larger treatment plan, but certainly not the only intervention. If you feel that he is appropriate for manipulation, I think that you should perform it as he seems to believe it will help. I feel that we should almost always attempt interventions that the patient thinks will help if there is no contraindication to the technique. I have some trouble addressing concerns that symptoms will return with cessation of medications in my patients. If the medication is an anti-inflammatory, I usually tell them that there are other ways to control inflammation aside from steroids if his pain does return. With this type of patient, I have progressively incorporated more SNAGs as part of the HEP to continue to address these hypomobilities.

Before this discussion goes to much further along this thread (to manipulate or not); I would make sure manipulation (Grade V techniques) were truly his expectations (“they popped and manipulated my muscles and it got better, I haven’t had trouble with it until now”); and his presentation is similar (non radicular this time); and indicated by a cluster of findings.

Not to derail the conversation/discussion; but here is a great library builder article with some things to think about with this case and similar patient presentations, especially when multiple directions of movement reproduce.
In my experience, this differential/thought process about the tissues is rarely on the minds of residents.

Think how it changes your treatment decision making versus add more energy into a system that is acutely inflammed inside the joint.

Food for thought – good article to review.

Keep up the discussion

Hey Katie! Thanks for posting. I feel that in response to your question about his fear of coming off medication you will have to have conversations on how PT and exercise can be its own natural “medicine”. With this I would dip further into pain theory and how finding some sort of physical outlet and exercise prescription in junction with PT techniques can help him manage his sx without the need to depend on drugs.

I was also wondering what you meant by saying this “type” of patient.

In response to the prior discussion to manipulate or not- I would probably be hesitant to do this day one and I would use mobilization techniques. As stated above by tyler I would be nervous to lose some bye in but I feel like the evidence Eric posted would be a great conversation to utilize with the patient describing the same effects can be reached with a less aggressive technique.

I think you mentioning that “This episode is worse than before, does not feel similar” would lead me to be sure that I though manipulation is appropriate this time around, relying on my clusters of symptoms/CPRs to help my potential bias (and his) towards picking a treatment based on someone else’s treatment. Sounds like he has already bought into the PT process, so I don’t think you are likely to loose too much by not manipulating the first day. I think education is key, giving him self treatments that are successful (whether its SNAGSs, stretches, etc) so he feels like he has control of his symptoms and may be less fearful when he finishes his medication.

Thanks for posting this article – entrapment or extrapment of a meniscoid is not usually on my mind when trying to determine the source of a patient’s cervical pain. Given that Katie’s patient responded well to distraction, then manual traction as a component of treatment makes sense. Considering that multiple directions/planes of movement provoked symptoms, I can see opting for mobilization over manipulation.
One of the patient’s goals was to learn some stretches to help the neck. With a patient like this, with multiple flexion and extension biased provocation of symptoms, I find it difficult to decide what type of neck stretches may be beneficial. I probably wouldn’t assign stretching for HEP initially. Does anyone else have difficulty with this?

After finishing Katie’s article, my oversimplified take away from the author’s conclusions is: Outcomes are no different if you pragmatically utilize thrust or non-thrust manipulations in this patient population. Did anyone come away with a different message?

After reading up a little more on the meniscoid, I would likely opt for cervical mobilization with this patient when you take into account the acuity of the condition and the fact that he is having pain with facet opening and closing. You can always consider thoracic manipulation to decrease some pain in the cervical spine if your patient ends up expressing the desire to be manipulated. That may be enough to satisfy patient while minimizing the amount of energy that you put through the cervical spine.

Justin, I had the same takeaway from Katie’s article, that it seems like a pragmatic approach is better than a prescriptive approach when it comes to outcomes (duh).

Hey Katie –

You’ve got some great information from the evaluation to start treatment.

I would add a few things:

– There is a tendency to group all neurodynamic testing into the median-biased test for the “catch-all”, however when you have such a specific route of pain along the posterior arm, I would test ulnar-specific ULTT to really rule out the neurodynamic component (especially if the posterior arm pain is reproduced with cervical flexion quadrant AWAY from the side of pain).

– The fact that you were able to reproduce his pain with compression, then immediately resolve it with distraction, is a powerful buy-in and educational tool. From this, I would go into teaching him self-distraction techniques for home to perform when he’s sitting throughout the day, rather than “stretches” (is flexibility really the issue?), then also use it to talk about load-sensitive tissues and positioning techniques to decrease pain. Manual traction is a great technique to perform during nerve glides, joint mobilizations, active movements, etc as he continues to improve.

– It’s interesting to think about biases with this patient because there are several reasons why you would classify this patient into a “mechanical” treatment classification (painful and hypomobile segments, pain with extension/quadrant, clear neuro), therefore go right into manipulation/mobilization, because we think mechanical = joint mob/manip. But, by doing this, you can at times bypass the most important information that you got from your eval, which for him were his load sensitivity and response to compression/distraction. Classification of clinical presentations are an important piece to the puzzle but you also don’t want to miss out on other asterisk signs that could potentially be more functionally meaningful at the start.

Sorry I have to miss journal club this month but looking forward to hearing about the discussion and continuing on the discussion board.