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Hey everyone,
Please see the updated patient case and questions with the associated article for Journal Club next week.
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1. Has he had neck symptoms or shoulder symptoms similar to these in the past. If so what did he do to resolve the issues or improve his symptoms. When he does get HA how long do they last and what does he do to resolve. Does he have any difficulty sleeping? Does time of day affect his symptoms?
2. I agree with your treatment for initial evaluation. Through mentoring I have learned to not try and fix everything and do too much day one. Keep it simple and improve presenting symptoms and give them a few things to work on and expand during follow up visits. I would consider doing a supine Tspine manipulation day one if they were open to HVLA techniques. Additionally for exercise I could consider Cervical SNAG’s to improve his Cspine ROM based on his objective exam.
3. When it comes to posture I usually borrow Kristin’s explanation she presented at weekend two demonstrating the normal curves in our spine in standing vs standing. From there I would ask him about his work place set up and explain to him the importance of keeping everything within arms reach so he is not leaning or reaching excessively for tools he needs. Educate him on chair height as well as computer and microscope height to hopefully relieve some stresses through his neck.
4. Yes I would consider a supine Tspine manipulation in this case. He has hypomobilities in his lower Cspine and tspine with resultant cspine rom restrictions as well as min pain levels at rest. Although the article you posted did not find significant differences between non thrust manipulation and thrust manipulation I have seen immediate benefits from supine Tspine manipulation for patients with neck and shoulder pain. Additionally after this past weekends course we see that it can have an effect on someone with low back pain as well. Thus we might be able to make a positive change on his secondary complaint of low back pain as well. -
1. Are HA one of his primary complaints, or are his HA just something that happens occasionally? If this is a primary complaint, I would have asked if he believes the neck pain and HA have a correlation to one another. I would also have looked closely at his upper cervical spine in the objective. Similar to Matt, I would want to know his 24 hr pain pattern for both complaints. If he has increased pain the longer he is at work and sitting, I would use this info for education later on about work ergonomics. Did any of your objective testing reproduce his lateral proximal arm pain? Were you able to reduce his arm pain with scap relocation or assistance test?
2. If most of his symptoms are occurring at work, I agree that postural education would be the first thing I address with him. I would also give him a doorway pec stretch and chin tucks that he can do at work. I would do snags, but have him do so to the L as to not aggravate his symptoms and to open up his R side facets. (Did he have pain with your PIVIMS/PAVIMs to the R?)
3. Again, if his pain increases while he sits at work, I would use this info in my postural education. I would discuss the effects of gravity on the spine in sitting vs standing. I would recommend he take frequent standing breaks or get a standing desk if easily available at his office. I would make ergonomic recommendations about his computer screen height and if necessary alter his seat height when looking into the microscope.
4. Yes I would consider using thrust techniques with this patient. I would try and determine if patient had a preference for this – if he had prior experience with a PT or chiropractor and if they used thrust techniques, if he believes what they did helped or not. It is also something to try that takes very little time to do. I would test-retest and see if it made cervical R SB or extension or right-back quadrant AROM any less painful. If he had less pain after the thrust technique, I would do it in the beginning of every treatment session, at least until his severity and irritability decreases.
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1) I’d be interested objectively in his DNF endurance, effect of CS axial compression/loading, where most of his extension comes from and if he’s hinging at a level, ergonomics of his desk outfit, and mobility of his first rib ispilaterally.
2) With these in mind and the given information, you could work in some upper TS mobs encouraging extension or maybe address painful facet closing R by using techniques that open facets on L at those levels depending on irritability.
3) For me, it would really depend on his ergonomic outfit of his desk. He’s a scientist, so I would probably get more success if I explained to him more directly that anatomy and involved pathology rather than using colorful analogies to dress up what’s occurring in his body. How was his test-retest for your asterisk signs? That’d be a powerful buy-in for a scientist to see a direct cause-and-effect.
4) I’d want to know more about his PMH to determine if there’s any red flags to be wary of, but otherwise he seems like a fair candidate. If you had significant success with local mobs to the lower CS, I probably wouldn’t use a thrust as a primary technique early in treatment since you’d have some home run hitters in the wings already.
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1. To better understand irritability: How long looking into a microscope or computer to agg? How about R cervical SB or extension? Immediate aggravation? Does he need to stop the activity or can he sustain the activity or position? Which symptoms, local or referred are reproduced with each activity? How long to ease with movement?
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Hey Cam,
Wondering if you’ve thought of assessing GH stability with this patient? After your presentation, it reminded me of one of my patients who has a very unstable shoulder joint with little tone, for reasons I won’t go into, but he presents with similar upper trapezius and lateral arm pain. Especially since your patients complaints are working at a computer and at microscope with his R arm unsupported (sustained traction) for prolonged periods. Just something to think about as a possible contributor or chronic MOI (if that’s a thing)? Just a thought!
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