January Journal Club Case

[August Winter]

Outcome measures:
NDI: 17
NPRS (current/best/worst): 4/2/8

Subjective: Patient is a 26 year old female who works as an RN and 2 weeks prior had a sudden onset of whole RUE numbness, R sided facial numbness, cyanosis of the R fingers, and radiating pain into the RUE after going to bed after work. Believing she was experiencing a TIA, pt went to the ER where a cardiac WU was negative. Pt later received C spine XR, which per her report revealed a R cervical rib. Since initial onset pt has been experiencing R anterolateral shoulder and R anterior neck pain described as muscle soreness, numbness in the R lower face/anterior neck/posterior R arm and forearm/anterior digits 2-5. Pt also reports hot/cold paresthesias in the hand but denies palpable or visual color/heat changes. Pt denies CN s/s. Pt numbness is typically worse in the AM, radiating pain worse in the PM.

– Aggravating factors: carrying any item > 5lbs in the R arm, helping with pt transfers
– Easing factors: activity modification (decreased lifting through that side, avoiding purse/bag on the shoulder, not reaching overhead with a load), rest
– PMH: generalized anxiety disorder, depressive symptoms, nonclinical insomnia

Primary hypothesis after subjective: neurogenic TOS

Differential list: vascular TOS, cervical radiculopathy, shoulder impingement syndrome

Objective:
– Cervical screen: compression and distraction in neutral and with flexion/extension biases negative, modified Spurling’s negative bilat. AROM: L extension quadrant, L SB, R SB, L rotation, and R rotation all minimally limited and reproduce minimal R anterior neck pain w/OP, all other motions nonpainful and WNL
– Shoulder screen: R shoulder flexion reproduce R anterior shoulder pain, reduced w/OP; all other AROM w/OP nonpainful and WNL. Resisted shoulder flexion and ABD 4/5 strength with minimal reproduction of R anterior shoulder pain
– Special tests: Roos + 20 seconds, Wright + at 90 deg ABD, costoclavicular maneuvers negative, Adson’s negative; no radial pulse changes noted during testing w/+ tests reproducing hand numbness
– Observation: FHP with increased shoulder IR bilat throughout subj/obj exam; no increased girth in the neck, no cyanosis/color changes in the UE, no abnormal venous prominence noted at superior chest/shoulders
– Neural testing: myotomes 4/5 C2 – T1 bilat, DTRs C5/C6/C7 all normal, inverted supinator present bilat, Hoffmann’s negative bilat; sharp touch sensation C2 increased, C6 and C7 diminished; median ULNTT wrist/finger extension, supination, ABD 90, initial ER reproduces R anterior shoulder pain, return to neutral and elbow to 65 deg flexion reproduces worst hand/posterior arm numbness and neck pain which diminishes w/cervical SB towards
– 1st rib: CRLF test negative for hard end feel, reproduces moderate anterior neck pain w/testing on R; R first rib elevated, w/caudal assessment reproducing facial > R hand numbness prior to R2
– Craniocervical flexion endurance: 6 seconds
– Palpation: R scalenes hypertrophied, w/light palpation reproducing worst anterior neck pain

Severity: moderate (symptoms impacting social function and work in addition to some ADLs)
Irritability: moderate (worst pain can last for several days occasionally)
Stage: subacute
Stability: improving

– Potential risk factors: current treatment for generalized anxiety disorder with changing medication due to side effects; physical and potentially stress inducing job as RN on a general medical/surgical floor

Treatment:
Visit 1: HEP including seated chin tuck, supine scapular depression nerve glider with neutral forearm, standing theraband scapular retraction and bilat ER

Visit 2: cervical SB and rotation w/OP does not reproduce any sx, scalene palpation minimally tender locally, R first rib caudal assessment does not reproduce facial sx but does reproduce hand numbness. Subjectively pt w/greatest sx provocation with feelings of increased anxiety following social event
– Scalene STM w/rib depression through strap, self scalene stretch using towel, scap retraction and depression seated over thoracic wedge, chin tucks. Increased sx in hand w/seated first rib mobilization

Visit 3: cancelled d/t stomach upset from medication

Visit 4: no sx at rest since the last session, although one instance of R shoulder pain during a controlled fall of a pt at work. Pt w/increased apprehension over work related exacerbation. Median ULNTT full excursion with L lateral flexion producing mod R thumb pain. Post treatment: full excursion with L lateral flexion producing min posterior elbow pain. 7.5 lb DB static hold at side no sx, 10 lb DB static hold at side produces R hand numbness
– Lateral cervical glides away with increasing R arm ABD to 90, scap retraction and depression seated over thoracic wedge, band ER wall slide w/chin tuck, UBE

Visit 5: increased stress after credit card being stolen, onset of R lateral forearm numbness proximally that extends to medial forearm and fifth digit distally. Pt reports having performed her HEP 3x/day. Median ULNTT no pain, ulnar ULNTT wrist/finger extension, pronation, ABD 90 deg, ER full, elbow flexion to 90 deg reproduces worst lateral forearm/medial hand/neck numbness and pain. Following treatment no resting sx, full ulnar ULNTT
– Median and ulnar nerve bias cervical lateral glides, scalene STM w/strap, cervical postural extension against pulley resistance, band ER wall slide w/chin tuck, elliptical

Visit 6: overall minimal sx after the last session, then one incident of 7/10 R facial, neck, and RUE pain following stressful work situation on Christmas Eve. Currently 3/10 lateral forearm pain. Radial ULNTT full IR, pronation, wrist/finger flexion, elbow extension, ABD 110 reproduces anterior shoulder pain which is lessened by finger extension to neutral. 7.5lb DB and 10lb DB static hold both increase lateral forearm pain. Pt concerns over needing surgery or change of career
– Radial nerve bias cervical lateral glides (no pain at rest, no change w/ULNTT), scalene STM w/strap, theraband shoulder extension, cervical postural extension against pulley resistance, scalene manual stretch into L SB/rotation away, elliptical

Visit 7: cancelled d/t stomach upset from medication

Planned assessment/treatment: GHJ mobility assessment, cervical CPA/UPAs

Initial PICO: In an adult patient with neurogenic TOS, would adding manipulation to the thoracic spine to standard PT care when compared to standard treatment alone, result in improved UE function and decreased pain?
Final PICO: In an adult patient with cervicobrachial pain, would adding cervical neural mobilization as an addition to typical PT care, improve UE function and decrease pain?

Discussion questions:
1. What has your experience been with evaluating and treating patients with TOS? What would you have done differently as far as initial assessments at the evaluation?
2. Before reading the article, what are everyone’s thoughts on prescribing some sort of self neural mobilization on the first day? What words do you use to describe either Elvey techniques in clinic or for self neural mobilizations that you have found patients understand?
4. Given the number of different structures which may be primary or secondary drivers of symptoms in a patient with TOS, I have had a hard time always pinning down exactly where within or between sessions to devote my time. What are some strategies that you have used to guide the focus of treatment in complicated patients (besides the clinical reasoning form!)
5. How do you approach conversations with the patient about changing careers/jobs depending on physical and/or emotional stressors that may be exacerbating their symptoms? What have you found that works? What have you found that has failed?

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[Erik Lineberry]

1 I think you did a good job of covering your bases with TOS and obj testing. To me you covered screening out cervical, thoracic, and shoulder involvement well.

2 I avoid prescribing NDT intervention on day 1 due to the chance of latent response when performing these techniques. I like being able to see the patient for a follow up to assess their sxs following IE before prescribing NDT intervention as part of the HEP. To describe neural mobilization in general and the theory behind a glider technique I like using bike brake cable as an analogy, since it has a sheath and the actual cable running through it. I will explain that you want the cable running smoothly through it, but sometimes the cable can snag or get compressed and then it will not slide as well. I heard it from somebody in my clinic and it made so much since to me since I have loads of it lying around. Unfortunately, not everyone knows what brake cable looks like, so it doesn’t always work.

3 ???

4 I think you did a great job of finding specific objective test-retest findings at each visit with this pnt and I think that is hugely important with pnts that have several sxs. You were able to assess a baseline, provide intervention, and reassess to determine the pnts response. This way you know for sure that the intervention is affecting their sxs in some way.

5 This is a tough one, especially for pnts that work in skilled labor. I have found that a lot of pnts in these careers do not feel like they can change jobs do to not having the required skills to perform a different task. I think it is always important to try to modify their environment first. When this doesn’t work, I think it is better to ask something like, “Have you ever considered a different job”? I think is a fairly open-ended way to at least see where they are at in thinking about how their job affects their daily life.

[August Winter]

Love that analogy Erik. Both cases that I have seen for TOS have been young, active individuals that I imagine would understand that analogy fairly well. I like that the physical structure is easy to relate to but also the motion/action. Being able to carry through the analogy and say, “Well when it’s not gliding as well you might not be able to brake as well (potential weakness) or might not have as much ‘touch’ with your braking (paresthesias)”. I tried to specifically use the language included in the study but it definitely felt a little lacking.

As far as a latent response, what are you more concerned about for a potential increase in sx, the patient’s buy in to your treatment plan or a prolonged flare up that severely impacts them for an extended period? Having not had the opportunity to make this mistake very often in my career I would love to hear other peoples’ experiences with having flared up a patient with a neurodynamic component either through the aggressiveness of the eval or through an HEP mobilization that is too aggressive too early.

I definitely think that activity/environmental modifications are an important part of making a particular occupation work. This patient is a nurse on a med-surg floor of a large hospital, so what modifications spring to your mind that might help her? We have not even touched on patient transfers and lifting mechanics, but this is a fairly young and new RN, so maybe there is work to be done there. Additionally, like our discussions on chronic pain, I like asking the patient questions versus always telling.

[Scott Resetar]

I had a cervical radiculopathy patient that I flared with a combination of aggressive mobilization and providing a nerve glide as an HEP. The guy was pissed, but it also really worried him. He thought he was getting worse. He was thinking about retiring in a few years and wants to sail around the Caribbean, and he was starting to think that this neck pain might be affecting him and he’ll need surgery.

Patient was improving so I thought it was okay, but obviously not. If the person has high fear, or anxiety, I would not usually prescribe something unless I had seen their response next visit.

You never want the patient to lose their confidence in you.

[nhoover17]

I agree with you Scott, about not wanting a pt to lose faith but I think there are effective ways to spin it to get them back onboard (sailing pun??)

I learned from a conversation with a CI that a simple explanation is that, although we like to be evidence based, PT is often an art and not an exact science. what works for one may not work for another. The important part is that we made a change in the environment, even if it was a negative change, at least we now know that we have affected the correct tissues and we can devise a new strategy for making positive change. Good change or bad change is better than no change.

I have used that fairly successfully with my patients since then. Especially those who become greatly concerned at the first sign of failure.

[Erik Lineberry]

I would hope that if the NDT intervention flairs the pnt up that their sxs would decrease with cessation of the technique. What concerns me most with prescribing it before fully understanding the pnt’s response is that they will continue to perform the technique as part of the HEP and continually irritate that tissue before their follow up visit.

I think body mechanics with her daily activities can definitely be beneficial, but I would also take with her about her stress levels. This is obviously an issue for her based on subjective with her nausea sxs, stolen credit card, work, and other life happenings. Recommending exercise as a means to reduce this or determining if referral to another provider is necessary could be beneficial for her.

[August Winter]

I had actually spoken to this patient about general aerobic exercise because she had specifically mentioned that she typically was very active but felt that she couldn’t do anything now. When I suggested TM/cycling/elliptical she made it very clear she was not a gym person and was more of an “activities person”. We discussed walking more, and just this past week she detailed having good stress relief with performing some simple yoga poses (childs pose, cat-camel) that helped her relax and did not bother her sx.

Your point about the HEP is very valid. Obviously there was the session that I increased her sx through the lateral glides, but then through other interventions I was able to bring her pain back down. My ability to decrease her pain within session is relevant to my ability to trial potentially more aggressive interventions at this point. For something like a self glide I can’t affect that irritability unless she immediately stops doing the exercise and emails me, something which most patients would not do. I can see how giving something like that as a part of the HEP after initial eval might be problematic.

[Scott Resetar]

1. I have only seen one patient with questionable TOS symptoms. It was during my first 12 week ortho clinical. She had shoulder instability, and then 2-3 sessions in, developed burning and tingling in the forearm and hand, worse with scapular protraction. We ended up doing a 1st rib manipulation, which relieved all her tingling and burning. It didn’t help her shoulder instability, and it was my first clinical, so take that for what it’s worth.

2. As Erik said, usually not first day due to possibility of flare, however I like that you prescribed a very conservative one the first day, and it involves a very small amount of scalene motion which could also be beneficial. Good choice!

3. I think the Eagles will win the Superbowl in 2018.

4. This is the pot calling the kettle black, but I think the obvious answer is to treat one thing for a good amount of time (5-10 minutes on scalenes) and then reassess. Better? great, those are likely involved. Next 5-10 minutes on pec minor, re-assess, etc on down the line of possible contributing factors. Anything that made improvement stays on your list of daily treatments/HEP/subsequent visit reassessments.

I say this, knowing that full well it is incredibly difficult to stay on task with something like this. I don’t have any special tips to stay on track, other than to stay with your clinical reasoning, and fight every instinct to just give the person scapular retractions, rows, and extensions out of inertia.

5. Tough question. Never an easy conversation. If it is truly exacerbating their symptoms, then a psych referral is warranted. I think that if you can demonstrate to the patient that their emotional stressors or psychosocial factors make their condition worse, they will buy in and maybe follow through with seeking psychiatric care. If this thing really isn’t getting better, and the person doesn’t want surgery to attempt to fix it, then a referral to a social worker or case manager would be warranted to discuss disability. That might really scare them or prompt them to agree with your recommendation to seek psych care. Sending back to referring MD is a must to discuss other treatment options and let the patient decide if those more aggressive treatment options are worth the risk, or if psych + PT can allow full return to work.

Honestly, I haven’t had to have that conversation with someone, but I know it will happen in my career at some point.

[August Winter]

Scott this patient had no previous shoulder issues or pain, but I definitely think I should have looked at GHJ and her scapula earlier than this past visit. I think I should have pushed to have her come in more frequently so that we could maximize time for treatment but also continue to evaluate other structures. In the last session this patient tolerated seated scalene MET w/first rib depression well, and so I think that I might trial a first rib manipulation in the near future, as initially she could not tolerate any pressure in that area.

The self mobilization has been progressed to a pronated forearm, shoulder IR, and legs in hooklying. I think decreasing the frequency of the intervention helped, as the patient was doing them much more frequently than I initially intended. I think this may speak to the irritabilty of those structures and the potential for flaring up patients.

[August Winter]

In thinking about it more, I know that the patient has had issues due to changing her medications for her anxiety, but I am not sure from what to what because she did not include it on the initial intake form. I have not asked her specifically but in conversation with her it sounds like her GP is managing her symptoms and not a different provider such as a psychiatrist. If she continued to have difficulties with stress management or had worsening anxiety then a conversation with her PCP and with her regarding other interdisciplinary care might be relevant.

[Michael McMurray]

1.I’m in agreement with Erik. You did a nice job with TOS and objective testing, as well as with your clearing screening. Personally, I have had limited experience with TOS. But for this specific patient, it sounds like addressing work related and psychosocial factors would be particularly beneficial. I would stick to your objective asterisks for treatment as you determine which structures may be involved and what treatments are beneficial.

2. I don’t typically give self-neural mobilization the first day in order to determine their response to the initial treatment. If that is a technique I’m considering as a part of a home exercise program, I’ll have them perform it during the initial evaluation or treatment; then prescribe it the next visit if there was no flare up.

4. I would continue to use your subjective and objective asterisks to guide treatment. I also agree with Scott that focusing on one potential culprit at a time will give you more information. I would continue to assess and re-assess after each different treatment and not muddy the waters. For example, if you perform soft tissue mobilization along the neural structures and mobilize prior to reassessment, it would be difficult to determine if both or which of those techniques was actually beneficial.

5. That’s a really difficult conversation. If it were something one of my patients was seriously considering, I would be potentially referring them back to the referring physician or primary care provider for further medical management. It’s such a life altering decision; I would want multiple health care professionals helping guide this patient. I would address this after determining the best patient specific approach, i.e. what kind of verbiage is appropriate and how the patient may react to what you say. As Scott said, I have not had this conversation with a patient but it’s a good reflection point as it is going to come up in the future.

[Michael McMurray]

What structures are being evaluation/stressed with the positive TOS tests that reproduced her sxs?

Those positive tests load specific structures in the thoracic outlet region.

The information gathered and the reasoning should guide specific treatment techniques directed at those tissues.

All that being said; a large percentage of these patients with a structural anomaly do not do well with conservative care.

[August Winter]

Adson’s scalene triangle, Wright either pec minor (90 deg) or costoclavicular space (max ABD), Roos potentially different depending on amount of ABD (we performed in 90 degree ABD and ER so likely pec minor), and costoclavicular maneuvers.

I also performed this test in our previous visit, although despite multiple trials on each side I could not appreciate any difference. Certainly nothing like in the video.

Scalene Hypertrophy

When looking at the special tests, I believe my difficulty with this case has come from the strong reproduction of her proximal and distal symptoms initially through light scalene palpation and caudal first rib assessment. All of these structures appear contributory to me, and weighing the percentage of involvement was not completely clear to me.

I was going to bring it up more in the journal club, but after looking a the radiologist impression and the radiograph itself, it would not appear that the patient actually has a cervical rib.

[Justin Bittner]

1. I have yet to treat a patient with TOS (on clinic rotations or since practicing). But overall, I think your assessment of structures and body regions was quite complete. Only thing to potentially add would palpation along neurodynamic pathway soft tissue; but I don’t think that would have changed what you knew already.

2. I used to give them regularly at evaluation until our 3rd weekend when we were taught that, that might not be the best idea. Luckily in that time time frame all those patient’s came back to the clinic without a very angry nerve. But since weekend 3, I have not given them day one. I may perform them day one and assess asterisks but now I do not give them as a HEP on day one.
When describing neural mobilizations, I typically will give some spiel about the nervous tissues needing to move through fascia just as arteries veins and other tissues need to. And essentially what I am doing is teaching the nerve how to move again by slacking one side and tensioning the other; and vise versa. However, I like Erik’s analogy.

3. A chameleon’s tongue can be more than twice the length of its body

4. I struggle a lot with this as well. In addition to what Scott mentioned, I have learned not to bail on a treatment if it doesn’t help the first time. If, based on your subjective/objective exam and clinical reasoning, treatment of the first rib is indicated, then perform a technique. If you reassess and do not note a significant improvement, it may be worth performing another bout or at least revisiting the intervention.

5.As Erik mentioned, certainly try to modify work. However, in this case it is emotional stressors. It is important to get the patient to understand how emotional stress can influence their pain first.
I have had one pt where emotional stress at work as a CNA was exacerbating her pain. I don’t remember how I initiated the conversation but we began talking about the parts of her job that seemed to increase her stress and anxiety. We then talked about ways to modify/avoid these stressors. I also initiated a conversation about what she enjoyed about her job. She talked about interacting/communicating with patients, talking to family members, and the appreciation patients had for her after getting “cleaned up”. She mentioned to me that she had never really thought about what she liked about her job and that she felt she might appreciate these moments more now during her day. So far it seems like it was a win, but time will tell. It was certainly an uncomfortable conversation for me as I was stepping into the unknown.

[August Winter]

Justin, I love the points you made about the job/career conversation. I know what things physically bring on her symptoms at work, but even when she talked about stress at work we didn’t dive into what other stressful nonphysical situations specifically seemed to affect her. I like the idea of asking about things about her work that she enjoys, as this might help as a coping mechanism for when she does have worsening sx.

[nhoover17]

1. I have never seen a patient with TOS so this was a very eye-opening case presentation. I don’t think I could have confidently been that thorough at the initial visit. How much of that did you get done on day 1?

2. Same as what Justin said, prior to VOMPTI class, I had been fine with giving glides or flossing on day 1 but I am less likely to do that now. As with everything else, discretion is the game we play. I think it is justifiable if you have some peripheral neurogenic symptoms but low severity and irritability and they have demonstrated quick on/off times.

4. I have struggled here because I have a hard time accepting that we dont have to have every answer on day 1. We have the benefit in our profession of multiple visits and constant reassessment so I think addressing what you can to show some improvement and then adding a piece in successive visits may be best, which is what it appears you did based on your progressing treatments at each visit.

5. I dont think I can answer this one without having been in that situation. I have taken notes from everyone’s perspectives above for future reference. For your particular case, I think this is similar to our pain science discussion in class on Sunday; there are so many ways to go. I think Eric’s analogy of “tossing out a little nugget” and seeing where it may lead is fitting and I like Justin’s approach of spinning it toward the positives. Maybe that discussion is a day’s treatment in itself, like Dhinu said, sometimes that conversation is more powerful treatment than being hands on that day.

[August Winter]

Nic, I definitely got more out of my conversation with this patient by taking the time at the start of the session versus trying to rush through. I think we talked for 10 minutes and then when we got to a point that I thought we were starting to be on the same page, we continued our talk while she was warming up on the elliptical. I found this to work well with several of my patients. I don’t rush talking with them but then wrap things up while they do something active. This isn’t right for every patient like this, but definitely has been beneficial for me when dealing with some chronic pain patients or patients with a more psychosocial element

[Myra Pumphrey]

August – Thanks for presenting this interesting case! Some thoughts:

She seemed to live with this anomaly w/o symptoms until recently. First, be sure you verify this when you do your subjective – ask thoroughly about previous history of symptoms. If this is so, ,I think there is a reasonable chance you can get her symptom-free again. What I would really grill her on is what was different during the time the symptoms started. What was she doing that day? Anything different at work? Changes in life stress? Anything that promoted sustained postures that would contribute? This can help you in your identification of associated factors to onset which will help you with treatment choices in regards to education.

In your exam, because of the distribution of symptoms, I would have evaluated ULTT w/ ulnar and radial n. emphasis on day one or two. Efficient to do all 3 when you do one. In regards to adding nerve glides when I have concern about irritability, I start with a conservative prescription, maybe 10-20 reps, 1-2 x/day, educate on responses that should lead the patient to discontinue the exercise, and see the patient for reassessment/progression in a day or two, if I have a high level of concern.

Anxiety – In addition to the pain science influences, there are other influences. When under stress, you are less likely to exercise consistently, less likely to pay attention to posture, less likely to do your prescribed home exercise program. I am sure to point this out. I would have started the pain science education early on in treatment, assigning her to watch one of the videos we have discussed in previous discussion. I would recommend having her document a certain number of minutes of moderate activity per week, starting with 150 minutes based on the documented benefits to general health, then progress her to 300 minutes per week.

Progression of treatment – I am seeing some very effective treatments that get stopped on subsequent treatment when additional treatment. I would recommend leaving in techniques that you previously determined were effective if there is still an impairment to treat and layering in new techniques/reassessing their effect.

[August Winter]

Myra, we talked about some of these points at the beginning of the journal club but I thought it would be good to highlight a few things because I think you bring up a lot of good information.

I talked with Michael about this after the evaluation, but her presentation of a more acute onset versus a progression of symptoms definitely threw me off at the beginning, but instead of digging more into what might have brought on her symptoms I just breezed right past that. I think given the number of other things subjectively and objectively that I did that evaluation I would have delved more into the history of the symptoms in the next session. I think that information is important and would have guided my treatment better, but I’m not sure if it would have changed my day 1 priorities.

As far as the PNE at the initial evaluation, I think that a more thorough subjective at the time would have revealed the connections between her symptoms and psychosocial factors, but at the time very little of that was showing through from what she was saying. This might be the patient that responds better to selected readings from one of our written resources so that it might be more individualized to her more acute situation. We talked about returning to becoming more actively aerobically again but I didn’t give her specific instructions, and this is something that I consistently make mistakes on. I think it’s important to still be prescribing that type of exercise, even if it does not need to be as specific as some other forms of therex we give.

Progression of treatment: 100% agree

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