May Journal Club Case

[Michael McMurray]

May Journal Club

Patient Demographic: 17-year-old female

Referring Diagnoses:
– Primary: Left leg pain, pain in soft tissues of limb
– Secondary: Quadriceps tendonitis, Patellar tendonitis of the left knee, Pain in the joint involving ankle and foot, left

Outcome Measures: LEFS – 7/80

Subjective: Patient is a 17-year-old female student with a primary complaint of significant left thigh and leg pain. Symptoms are of insidious onset beginning more than 2 months ago that have progressively worsened. Initially, pain in the left leg proximal to the ankle and has now progressed upward into the left thigh. Currently, patient reports pain in the entire thigh distal to the hip, leg, and foot. It started as a dull achy pain which has graduated to an excruciating, stabbing pain. She reports color change to deep purple with exacerbation of symptoms. She also notes that her nails have become brittle. Currently, pain is a 4/10, at worst it is an 8-9/10, and at best is a 3/10 on the VAS. With ‘episode’ of symptom exacerbation patient report shaking, difficulty breathing and crying.

Patient reports prior to onset of symptoms she had residual knee pain from a left knee injury in early 2016. Patient had 8 weeks of physical therapy followed by left knee surgery in March 2016, then another 4 weeks of therapy. Symptoms never completely resolved.

Prior to the onset of current symptoms, patient was able to complete all ADLs without difficulty. She is currently ambulating with 2 axillary crutches ½ the day when she can no longer tolerate weight on her left leg. Patients describes difficulty concentrating in school secondary to symptoms. Her goals are to be able to walk without crutches and return to softball.

Description of Symptoms
– Current: Sharp stabbing pain, worse along the anterior leg and thigh
– Aggravating Factors: Weight bearing without crutches, touch, temperature changes, dependent positioning, movement of the ankle, knee, or hip
– Easing Factors: Elevated positioning, warm water baths (if patient does not move)

History of Present Illness
– Arthoscopic Knee Surgery, Left Plicectomy
– X-ray, Foot, Left, AP, Lateral and Oblique Views
o Impression: No evidence of acute displaced fracture or dislocation.
– Ultrasound Doppler, Arterial Left Leg
o Impression: No arterial stenosis or occlusion identified.
– MRI of Knee, Left, WO Contrast
o Findings: Mild left knee joint effusion, no significant popliteal cyst. Cruciate and Collateral ligaments intact. Mild Tendinopathy of the quadriceps femoris tendon and proximal patellar tendon. Minimal fluid in the infrapatellar bursa. No meniscal tears identified.

Previous Medical History: Significant for scoliosis, patient does not believe this is related to current symptoms.

Primary Hypothesis after Subjective: Complex Regional Pain Syndrome (CRPS) of the left lower extremity

Objective
– Observation: Patients left thigh and leg are of blotchy, purple coloring. Atrophy noted in the posterior calf and anterior thigh.
– Active Range of Motion
o Hip Flexion: 100 degrees
o Knee Flexion: 110 degrees
o Knee Extension: 0
o Left Ankle: Severely limited actively in all directions
– Sensory: Patient winced and had significant withdrawal and was unable to tolerate touch throughout left lower extremity
– At this time during the objective exam, patient and parent became very emotional

Primary Hypothesis after Objective: Complex Regional Pain Syndrome (CRPS) of the left lower extremity

Severity: Severe (symptoms are affecting ADLs, school, and ability to participate in age appropriate activities)
Irritability: Severe (patient reports exacerbations of symptoms that can result in excruciating pain with an emotional response, can last for several hours)
Stage: Chronic
Stability: Worsening

Initial Treatment:
– Patient and Parent education regarding CRPS and pain neuroscience
– Ambulation: weight bearing as tolerated using 2 axillary crutches
– Active Range of Motion: Hip, knee, and ankle as tolerated or until fatigue

Current Treatment:
– Over the course of the first several treatments
o Limb laterality recognition via Recognise iPhone Application
o Imagined Movements
o Grated Motor Imagery, seated and in long sit position
o Seated thoracic physioloigical motion

Discussion Questions:

1. What, if any, experiences have you had in treating CRPS? What treatments have you found to be beneficial?

2. This was one of my first experiences having an emotional patient and parent. How can a physical therapist best handle situations such as these?

3. Generally speaking, when a CRPS patient’s symptoms continue to worsen and there is not a positive response to treatment, at what point should a Physical Therapist refer them back to a PCP or specialist?

4. An article by Menck et al. (2000) entitled Thoracic Spine Dysfunction in the Upper Extremity Cronic Regional Pain Syndrome Type 1, discusses utilizing thoracic manipulation for patients with CRPS to affect the sympathetic nervous system. I started utilizing thoracic physiological motion as a treatment. Any thoughts regarding the idea of utilizing these interventions to improve her left lower extremity symptoms?

Article for Discussion: Graded Motor Imagery for Pathologic Pain: A Randomized Study

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[Scott Resetar]

Did the patient have any other the other symptoms of CRPS like changes in hair growth, sweating, skin texture changes, skin temperature changes?

1. One patient with highly questionable CRPS currently, as noted in the “all brains on deck” post. I also had one mid 20’s female patient during my final clinical rotation, again highly questionable CRPS diagnosis as no skin or trophic changes, more likely just chronic shoulder pain. This patient benefited from the recognise app, mirror therapy, meditation, and long sit slump neurodynamics. Patient had immediate sweating response and increase in body temp when we did long sit slump with thoracic rotation exercises.

2. With poise. My fiance is a pediatric PT so she can probably give a lot more information re: dealing with parents. You have to sell both mom and child on your treatments. some 17 year olds are nearly full adults and will be IND with HEP, others are still very much children and won’t do anything. I think this is a tough situation as you need to discern a lot about the child/parent relationship. Is mom being overprotective and exacerbating the emotional problems?

3. As quickly as possible. I would try to get the doctor on the phone and advocate for psych referral, and possible medications like sympathetic nervous system blocking agents, or neurontin/gabapentin maybe? previous cases have also been treated with antidepressents

4. Seems plausible to me. As Eric Magrum once said, it’s all about the re-assess. If it works, keep doing it. Scoliosis could effect sympathetic chain, but might change your ideas for manipulation if her scoliosis is too severe.

[Michael McMurray]

Good Question, Scott.

She had some skin changes (shiny), brittle nails, and temperature changes.

At that time she did not have an increase in sweating or hair changes.

[August Winter]

Katie, how are you tracking the area of symptoms currently? Mapping it out like in the LANSS or taking pictures?

How often are you seeing this patient?

What does this patient do to cope with her symptoms? Were there emotional triggers early on that contributed to these symptoms?

1. None at this point. I do have a patient s/p plical excision with some impressive color changes (deep purple) around her patella but seemingly none of the other signs of CRPS besides a high level of pain. For this patient using TENS has helped her be able to do more strengthening in the clinic without a greater flare up in her symptoms. I’m not sure if your patient could tolerate this sort of intervention at the moment, but maybe further down the line when strengthening might be indicated.

2. I have not had this situation nor would I pretend to know how to best navigate this situation. I think I would fall back on what helps me with any emotional patient: body language. I try to make sure I lean forward, make eye contact, not cross my arms etc. I think just listening without trying too hard to redirect back to the matter at hand typically works the best.

3. Again I’m not sure if I have a great answer for this. I think keeping contact open with her PCP might be a good step, but it would be helpful if there were some kind of management tree/algorithm for CRPS. What sort of specialist in your area would you want to send this patient to?

[Michael McMurray]

Hi Katie
I had a very similar case with a 16-year-old cheerleader. She had a very similar presentation 8 months s/p Fulkerson osteotomy.
A couple things that I found helpful:
– Explaining to my patient as well as her mother the “Pain Meeting”
My patient was an honor roll student who was suddenly struggling in school, having trouble concentrating and dealing with the “high school drama” of not being able to cheer at games and loosing captain status due to her inability to WB by the end of the day from pain and swelling.
– Over time we noticed increased school stress worsened sx as well as spread sx up her leg (from ankle to thigh). Originally she came to therapy at the end of the day which was also a big factor because by the end of the day she was already in so much pain.
– we changed her appointments to 7am before school which greatly impacted how much more we could do in therapy.
I educated the patient on the effects pain has on the pre motor cortex (Affecting movement, motor control), cingulate cortex (concentration, focus), pre frontal coretex (loss of memory, problem solving difficulties), sensory cortex (difficulty with laterality ex R and L discrimination), hypothalamus (lack of motivation)…… ect.
Patients want to know the WHY so being able to provide some scientific research studies to support some of these issues as well as support for the treatment interventions was a huge breaking point in my treatment intervention with a 16 year old.

I noticed you mentioned you were using the Recognise app, how did you assess it? I know that was something I didn’t pick up on during my first few treatments, but once I did the app was really helpful. I had the patient use it as part of her HEP and we used the graph to compare her progress, as well as a self motivator. I also mixed up the limbs so she had to differentiate between upper and lower extremity R and L as her scores improved with # of correct answers as well as decrease time to answer.
I also made a texture want for my patient we numbered them so we could keep track of what textures and how many times she could tolerate the strokes. Having her keep track of her progress helped motivate her. The instructions I used were to start with the soft “good feeling silky texture” and progress to texture 2-4 (which were rougher surfaces).

-I did end up referring my patient back to her PCP around week 6 when we were hitting a plateau, her sx had localized from entire leg to just ankle, but she was still having significant and debilitating swelling along with pain and color changes…. The PCP put her on antidepressants for 6 weeks and that in combination with therapy her sx resolved enough to the point where she returned to cheerleading and “light” tumbling. At that point we slowly transitioned to once every 2 weeks, and once a month, and I continued to see her for a total of 5 months at which time her sx had significantly resolved and we were primarily catching up on orthopedic impairments/muscular strengthening.

I found Adrian Louw “Teaching People about pain” on medbridge to be a super helpful tool, definitely check that out if you haven’t.

[Justin Bittner]

Interesting case Katie.

1. I currently have one pt with CRPS of her R foot and ankle. She is a 23 y/o female that tripped chasing her cat many months ago. Things that have been beneficial for her are mirror therapy, graded exposure (I have messed up on 2 occasions with this and flared her up), thoracic physiologic mobilizations in sympathetic slump positions, thoracic manipulation, deep pressure with physiologic movements (this has progressed as her sensitivity to touch improved).

Some asterisks I have used were skin temperature at 1st/2nd web space, medial and lateral malleolus; sympathetic slump, active and passive LE movements.

2. I have not had an emotional parent and child at the same time. This is a tough one. I feel like I would probably, as August said, try to listen to them and their concerns, asking their goals, and explaining clearly what I have to offer them. Sometimes this can be enough.

3. If symptoms continue to worsen, I would likely try to get the MD on the phone to explain the situation with a couple weeks depending on speed of worsening symptoms. I would like to say I would recommend sympathetic medication or psych eval like Scott mentioned even though I find these conversations still difficult to have. I generally try to say what I have to offer musculoskeletal wise and how other systems can effect pain and the nervous system. I try to spin it in a way sounding like I can help “xyz” while your physician can help with “abc”.

4. With my current pt I have used thoracic manipulation. She demonstrates positive sympathetic slump that is improved following thoracic manipulation. I have also found the physiologic mobs in sympathetic slump to be just as effective for her. I made sure I explained to her day one that the thoracic spine may likely be an area of treatment so she was more onboard at follow-up visits.

[Katie Long]

Katie, this case is definitely a tough one, but it sounds like you are already doing some great things.

1. I have not treated any patients myself with CRPS, however during the last week in my last clinical rotation (SNF) we had a patient put on our schedule that we didn’t normally see s/p ankle fx 2/2 fall who I was very concerned had developed/was developing CRPS. She had severe sensitivity to me taking her sock off to inspect the area, she had redness from the toes to the mid-tibia, lack of hair in the same distribution, as well a shiny and tight skin appearance from toes to just proximal to the ankle. I alerted the nurse to the appearance and my concerns, however I never got to follow up on the patient since I never had them on my schedule after that.

2. I have had limited parent+patient interactions and even more limited experience with emotional patients specifically during evaluations. But similarly to what August mentioned, I think body language is important and making sure the patient knows that they’re being listened to. At that point, I think building a positive relationship with the patient can be just as important if not more so than the objective data that can be collected at the next follow-up.

3. I think in this case I would want to keep an open line of communication with the PCP/referring doctor. I would want the patient to know that we are all on the same healthcare team and are all playing our part to help her get better. I don’t think its something I would initiate first day, but something I would want to do within the first couple of treatments.

As stated previously, I don’t have any personal experiences treating patients with CRPS, but I wonder about treating them similarly to a peds patient with tactile defensiveness? Maybe utilizing something like shaving cream to get her touching her limb and introducing gradual tactile stimulation (similar to what Michelle mentioned above?

[Erik Lineberry]

1. I have not had any experience with CRPS, I look forward to hearing from others experiences with this condition.

2. Having multiple people involved in a single case always makes things trickier for me. As others have already stated getting buy-in from multiple people can be difficult. The way I approach building rapport with people varies significantly based on a person’s personality. This is true for spouses, family members, parents, etc. It comes down to reading people and understanding if it will be better to explain treatments/POC individually or as a group. Expecting what each member of the patient’s support group will respond to is an important part of care. How were both the patient’s and parent’s response to her condition and your exam/treatments?

3. If the patient is truly declining each visit and I have modified my treatments accordingly I do not think I would continue to treat them without at least a second opinion for longer than 2 weeks. That being said, I think it is important to make sure the patient, parent, PT, and PCP know the expected response to treatment is and what the prognosis is. When a patient has a bad day and you guys have already talked out what to do about it, things will be 100x better than if they have been steadily improving and all of a sudden they have a set-back. I have let that bite me a few times with patients that I knew may have an up and down trend to better instead of a linear one.

4. Everyone needs their T-spine manip’d, it cures all. In all seriousness though, I could see how this treatment may help. I am always concerned about a possible negative response to manipulation in patients with chronic conditions. I have found it hard to build rapport and easy to lose it with these folks. I tend to start gentle and build trust prior to manipulation, which sounds like what you are doing. What Scott mentioned about test-retest hits home for me. If it works, don’t fix it. What has her response been to your thoracic intervention? Do you feel like you are stimulating the sympathetic NS with the physiologic motion you are providing or is there another mechanism at play with this intervention?

[nhoover17]

1.
I have not treated or seen CRPS personally, so it has been quite a learning experience reading everyone’s thoughts and cases

2.
I think the most important thing, which is kind of the backbone of what we do, is to listen, as everyone has already mentioned. In my experience, These kinds of patients have been to several health care visits and are overwhelmed with information and worries. As Justin said, if you can establish an outline of expectations for them to get a clearer picture of the plan that helps. I also had a CI during one of my clinical rotations who would pray with patients if they were accepting. I know that’s not everyone’s thing but if religion is important to them and you can establish a rapport that way, it can be a very valuable connection.

3.
It’s hard to answer this without having experienced it but I think my gut reaction is similar to the above responses. I would try to be in contact rather early just to gather as much information as possible to establish the best POC, and then keep in touch depending on the patient’s progress.

4.
I think it is certainly feasible that Tsp manipulation can influence the nervous system enough to at least open a window of opportunity with this population, assuming they can tolerate it. After a quick search, I didn’t see any articles that jump out right away that would discourage it. I think it would actually be more tolerable for CRPS in the LE compared to UEs just based on testing position alone, not directly contacting the LEs like you would with UEs.

[Michael McMurray]

Attached is table E-1 describing subject characteristics referred to in the results section.

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[Myra Pumphrey]

katie – Thanks for presenting this interesting case! I would not hesitate to refer this patient to a psychologist. It is an opportunity, really, to address likely ‘associated’ factors. I would approach it as being a very difficult life experience – she would benefit greatly from having a non-biased professional (not just family) help her through this and give her advise/strategies to help her manage.

I also agree w/ assessing/treating neurodynamics, as indicated.

Prognosis: I expect this to be prolonged process – I do not expect quick or huge changes on reassess and reassessing will be easy through all of the ways discussed during your presentation.

Treatment: In addition to all you mentioned, I would use A LOT of PNF principles/techniques with her. Specifically, you can use functional patterns which cross mid-line, using visual tracking during the pattern for repeated recognition of the affected limb. Also, you can treat her affected side indirectly by using full body patterns through the upper extremities to encourage work and weight shift to that lower extremity through a developmental progression (starting with supine, then to rolling, sitting, then PWB standing to FWB as tolerated. You can also use bilateral lower extremity patterns to facilitate overflow activity from un-affected to the affected side. If she can’t move through a full range of a pattern with the affected side, you can assist with the un-affected side, which will facilitate recognition and help her repeat normal functional patterns of movement w/ better tolerance. If she can actively move through a normal pattern but can’t tolerate resistance, add resistance on the unaffected side, again, for facilitation/overflow.

Again – I would use a ton of visual tracking of the affected limb during exercise.

[Michael McMurray]

Here is a case report on CRPS in a young adolescent female post chronic ankle sprain/MVA. There is a gap in the literature in this particular area which creates an excellent opportunity for us to try to submit case reports for publication… just food for thought.

Keep us posted on progress Katie.

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[Stephanie Roane]

Hey guys- Just to quickly introduce myself, I’m a former resident and am back working at UVA-Healthsouth.

I sat in on the Journal club discussion and spoke to some of the questions surrounding normative data when utilizing the Recognise app. I very recently evaluated a worker’s comp patient that was referred for CRPS so did some recent reading to catch myself up on treating this condition as “true CRPS” isn’t that common for me to see in the clinic.

If you go to the Graded Motor Imagery website from the Noigroup you can find ‘normal’ results they suggest to guide you with your patient as they practice left/right discrimination … Graded Motor Imagery

This is directly from the website…

So what is normal
-Left/right judgement tasks are required to fall within a certain range of speed (average response time in seconds) and accuracy (percentage of correct answers) to be considered as normal.

Our broad suggestions for normal responses to a left/right discrimination test are:

-Accuracy of 80% and above.
-A speed of 1.6 seconds +/- 0.5 sec appears quite normal for necks and backs.
-Hands and feet are a little slower with an average speed of 2 seconds +/- 0.5 sec.
-Based on these figures we would suggest that around 2 seconds is quite normal for other body parts such as knees and shoulders.
-Accuracies and response times should be reasonably equal for the left and right.
-Results should be stable (eg they don’t fade out with stress) and are consistent for at least a week.
-A judgement will also be needed on the personal relevancy of the responses. For example, minor left/right discrimination changes may not be so relevant in a person who has a severe pain related incapacity whereas they may be more relevant in a person with a much more minor problem. This is a clinical reasoning judgement.

NOTE: these ‘normal’ results are based on studies of hundreds of people and act as a guide only. There may be reasons why, after months of practise, you still find it impossible to get results within these normal ranges. Aim for the normal range and give it a real go but don’t be upset if you can’t get there!

It’s certainly worthwhile to check out their website which is supporting information to their Graded Motor Imagery Handbook. Great job with the case. Hope you guys find this helpful.

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