November Journal Club

[awilson12]

Have a look at the case and articles. Looking forward to discussing it with everyone!

Questions:
1) Is there any more information you would have gathered during the subjective? Are there any other outcome measures you would have administered?
2) Based on body diagram and subjective exam is there anything else on your differential list? Is there anything you would change on mine?
3) Considering irritability would you have changed your objective exam? What would you have done differently?
4) What is/are your primary hypothesis or hypotheses?
5) What would your PICO question be for this patient?

Some things to think about for the articles for Journal Club discussion:
– Strengths and weakness from a research design perspective
– Strengths and weakness from a clinical application standpoint
– Are the reported results actually supported by the data/as meaningful as they make them seem

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[helenrshep]

1) Is there any more information you would have gathered during the subjective? Are there any other outcome measures you would have administered?
– I tend to do QuickDASH for elbow and hand and SPADI for shoulder, so I probably would do SPADI though I don’t think you’re wrong! Maybe NDI as well to capture neck contribution.
– I might want to know more details about the MVA/imaging – how fast was the other car and her car going? Did she have anyone with her? Did she go to the hospital from the wreck or was the imaging later? How did she feel that day and the next day compared to now?
– How long has she been on light duty/what does that entail compared to her normal responsibilities?
– Is she normally a R side sleeper/is her sleep disturbed?
– How much/how often for the meds (NSAIDs and muscle relaxer) – wondering if we are getting a true/clear picture of her symptoms/irritability based on when she last took something, and curious about how much work it will take to get her off of them

2) Based on body diagram and subjective exam is there anything else on your differential list? Is there anything you would change on mine?
– I still have upper cervical instability on my list (did the imaging just rule out fracture/what about ligamentous laxity?)
– I think I’d have the cervical stuff higher on my list until proven otherwise. I feel like neck movement affecting shoulder symptoms tends to be more neck pathology vs a true shoulder pathology may be less affected by neck movement

3) Considering irritability would you have changed your objective exam? What would you have done differently?
– I think it depends on why you have mod/severe for irritability – once her symptoms come on, how long does it take for them to subside? We know arm movement brings on all the symptoms, but do they go away pretty quickly once she returns to resting position?
– I think your exam was great! I’m curious if her cervical symptoms with AROM would change if you unweighted the shoulder girdle by putting her hand on her opposite shoulder.
– Cervical radiculopathy cluster?

4) What is/are your primary hypothesis or hypotheses?
– WAD, C5/6 radic

5) What would your PICO question be for this patient?
– In patients with WAD, is manual therapy or manual therapy with exercise more effective for restoring cervical range of motion?

[lacarroll]

Questions:
1) Is there any more information you would have gathered during the subjective? Are there any other outcome measures you would have administered?
– I was curious if she sought out medical treatment immediately after the wreck and if she was the driver or a passenger, but other than that I think you did a great job of collecting a lot of good info.

2) Based on body diagram and subjective exam is there anything else on your differential list? Is there anything you would change on mine?
– Not really. I agree with WAD as number 1 for the differential, but I’m curious what made you put cervical & discogenic lower on your list than impingement and some of the myofascial components.

3) Considering irritability would you have changed your objective exam? What would you have done differently?
– I definitely think I would have been pretty conservative with the objective exam on day 1 if she was super irritable. Did she mention how long it takes for her symptoms to decrease at initial eval or did I just miss that somewhere? Also, how much of the objective did you get done on initial visit versus first day of treatment?

4) What is/are your primary hypothesis or hypotheses?
– I’m sticking the WAD with the mechanism and host of shoulder girdle and cervical impairments that seem to be going on with this patient.

5) What would your PICO question be for this patient?
– In patients with WAD, does manual therapy decrease recovery time?

[Steven Lagasse]

1) Is there any more information you would have gathered during the subjective?

Quality of headaches and what triggers them (light vs. movement, etc.)
Is there an epicenter, or does one symptom appear to be causing the other symptoms?
How have these symptoms evolved over the month?
Was she the driver or passenger?
How soon after the MVA did symptoms come on?
What is her mentality regarding this accident?

Are there any other outcome measures you would have administered?

NDI, and perhaps something for depression. My clinic only uses FOTO so my experiencing with using other outcome measures is quite limited.

2) Based on body diagram and subjective exam is there anything else on your differential list?

It’s easy to think of an all-encompassing list when there’s plenty of time to reflect. Some additional differentials that I think might be warranted are…

Cervical Radiculopathy
Thoracic referral
1st rib
Scapular Dyskinesia
Ligamentous injury (Neck and/or shoulder)

Is there anything you would change on mine?
Is WAD appropriate to be on the differential? I feel like this is more of a treatment guideline regarding rather than a hypothesis. I could be wrong about this though.

3) Considering irritability would you have changed your objective exam? What would you have done differently?

Hard to say. For me, it depends on the patient’s affect, and demeanor. So long as they were tolerating the exam well and weren’t having pain with all tests/movements I would likely have continued.

Cervical Spine: In a perfect world I may have thought to perform the radic cluster, flexion with compression and if provocative, cervical distraction to see if that changed their scapular symptoms. Unweighting the shoulder girdle and performing cervical ROM. Neck flexor endurance testing may have also been helpful.

Shoulder: Perhaps some lag signs if the patient was able to tolerate them.

4) What is/are your primary hypothesis or hypotheses?

Maybe a cop-out answer but based on what we know at this point, this presents to me as a heightened system with a host of myofascial components. This is, however, contingent on how the radic cluster played out.

5) What would your PICO question be for this patient?

Manual therapy versus exercise for return to work in young adults post motor vehicle accident

[Michael McMurray]

1) Is there any more information you would have gathered during the subjective? Are there any other outcome measures you would have administered?
-Was she the driver or the passenger is the car? speed of cars? seat belt?
-Hx of headaches, neck pain, shoulder pain
-Any concussion symptoms (loss of consciousness, difficulty concentrating, etc)
-Persistance of symptoms?
-Possibly NDI

2) Based on body diagram and subjective exam is there anything else on your differential list? Is there anything you would change on mine?
-I think you have a strong list of differentials

3) Considering irritability would you have changed your objective exam? What would you have done differently?
-While you stated the irritability was mod-severe, I would like to know the persistance of symptoms, to see how symptoms responded after being increased.
-How were R rotation, SBR, extension, and the other quadrants? Was the cervical ROM limited?
-Also, you did state you performed them over two visits, so it seems as though you may have altered your objective exam for that reason. I would be interested to see which findings were on initial eval and first follow-up and the time between.

4) What is/are your primary hypothesis or hypotheses?
-cervical facet dysfunction with Myofascial involvement

5) What would your PICO question be for this patient?
-In patients with cervical facet dysfunction does PA mobilizations and exercise improve ROM and decrease disability compared to exercise alone.

[Taylor Blattenberger]

Questions:
1) Could have had her fill out an NDI, but the QuickDASH does have relevant items for this case. Great job looking for her different symptoms, I want to know more about the way they come on. Is it immediately? After 10 min? An hour? Do they all start at the same time, or does the neck hurt first, then the shoulder? That sort of thing.
2) Great list, Maybe add thoracic facet referral.
3) I liked the level of rigor you used in your exam. ROMs provoked almost all symptoms (besides headache) and it may not have been necessary to do too much else at this time. With the info presented I’m having a tough time distinguishing this as a disc pathology or myofascial. Did you do compression? I also want to see what the neck ROM looks like when the myofascial structures are unweighted. That would be a quick test to differentiate the 2.
4) Cervical myofascial strain + Subacromial pain syndrome – biceps tendon and RC tendon involved
5) For a 28 yo female with neck pain post MVA, are thoracic mobilizations as effective as cervical mobilizations at decreasing pain with active movement. – You describe this patient as highly irritable, so what is the utility of treating away from the most irritable region. Full disclaimer, if this was my patient and this was my question I would assess the T/S for hypomobilities first.

[pbarrettcoleman]

1) Is there any more information you would have gathered during the subjective? Are there any other outcome measures you would have administered?

I find with MVA an Impact of Events Scale gives you a lot of insight into the yellow flags surrounding cases like this. I would have also liked more detail about exactly what occured during the MVA (body positioning, what happened immediately after, etc).

2) Based on body diagram and subjective exam is there anything else on your differential list? Is there anything you would change on mine?

I think you have a strong differential list.

3) Considering irritability would you have changed your objective exam? What would you have done differently?

This is hard to talk to without having the patient in front of me to gauge their reaction/buy in, but I might have been hesitant to do quadrant testing on day one due to it being the most provocative test. You also withheld mobilization testing which was probably appropriate given that amount of irritability.

4) What is/are your primary hypothesis or hypotheses?

I’m not sure how to describe this or if we have enough information yet due to irritability being so high and not being able to test a few more things out (I don’t see we reproduced the HA, but we PA testing was withheld so who knows). Right now, I feel comfortable saying we have some upper cervical, mid cervical, shoulder, and myofascial impairments.

5) What would your PICO question be for this patient?

Is manual therapy or therex better for people who have been in a MVA.

[awilson12]

Thanks guys! All good questions and points to consider.

Response to first question-
a. Agreed, NDI could have been another outcome measure I could have administered (the front office staff gives them out based on body region and her referral was for shoulder). I was also thinking along the lines of impact of events scale or FABQ that could have provided some good information.
b. More information on the MVA- she was the only one in the car and was stopped at a light and someone hit her on the driver’s side going about 30-40mph; she had immediate onset of global pain and was taken by ambulance to the ED where she got imaging (CT of chest, head, and neck; XR of chest, shoulder, and spine; later got MRI of shoulder)
c. Mentality after MVA- no litigation, insurance taking care of car and medical bills; generally frustrated at not being able to work and do every day things
d. Progression of symptoms since accident- got better over 3 week period of not working, went back to light duty and got progressively worse over 2 weeks leading up to seeing me
e. Light work duty- she had been on light duty for 2 weeks at this point; as much as possible she wasn’t having to help with patient transfers, hanging IV bags, and was allowed more rest breaks, but due to the nature of the job she sometimes had to do more than she would have liked
f. Sleep disturbances- unsure about which side she usually sleeps and sleep was disturbed but wish I had more information to give you than this in terms of how often, how long she was awake, etc. so definitely a good line of questions to store away for future use
g. Medication- only takes muscle relaxer before bed b/c made her sleepy/groggy; not on any opiods at this point b/c doesn’t like how it makes her feel; on prescription NSAIDs and taking every few hours as prescribed; unsure the time frame of taking meds and coming to PT; good point about asking more (especially at this point being a few visits in) about how often she is taking them since progressing in PT and gauge her feeling on decreasing utilization
h. Headaches- definitely could have been more specific in querying about headaches; all I know is that they were R sided and she has had them just about every day since the accident
i. No prior history of headaches, neck, or shoulder pain; did not present with any concussive symptoms and denies any following the accident
j. Regions of pain- thoracic region pain was severe and constant and increased with shoulder movement > neck movement; shoulder/chest pain was reproduced with shoulder movement (especially more quick movements or reaching overhead) and relieved by rest; neck pain was reproduced with neck movement and slightly with shoulder movement but was less than other regions

[awilson12]

2) Definitely some good additional differentials to think about
a. I didn’t include cervical radi b/c I felt like the symptoms and aggravating factors didn’t sound neurogenic in nature to me; however, I think with there being neck pain and distal symptoms cervical radic would have been a good addition
b. Steve- that may be a good point of WAD being more of a overarching term (like chronic low back pain or patellofemoral pain syndrome) vs a specific diagnosis; my line of thought in including that is that in this situation there might not be one consistent driving factor due to the circumstances of the event and over the first couple of visits as irritability decreased I was able to more specifically rule in and out different things to hone in on more specifics of what was going on

THOUGHTS FROM THE REST OF YOU ON WAD BEING A DIAGNOSIS?

c. Helen and Lauren- after subjective cervical was definitely higher on my list than how I have it listed (retrospectively writing the case up I just put down differentials & was biased by what I already knew so I didn’t really order them specifically how I had them ranked after my subjective so that’s my bad)
d. Helen- in terms of ligamentous laxity it was something that I looked at during my objective so definitely appropriate to have on my differential list; they did pretty comprehensive imaging but still something to keep on the radar with trauma involved

3) I choose mod-severe irritability after subjective b/c the thoracic region pain was constant, seemed easily aggravated, and when it got really bad could lead to severe pain for 1-2 days; shoulder and neck were less irritable and took longer to get to the point of lasting symptoms for a few hours –> throughout the exam she tolerated AROM well but after this point started to report steady increase in symptoms
a. Day 1: only mid cervical AROM- all straight planes and front quadrants (not sure why I didn’t do back quadrants or if I just didn’t remember to document this), shoulder AROM (flex, abd, ext, ER & IR at 0), ER/IR resisted testing, palpation
b. Agreed, with this information it is definitely difficulty to determine disc vs myofascial; I did not do compression testing or attempt to unweight myofascial structures which I feel like with the tests I was already doing would have been something worthwhile to throw in without adding too much to aggravate symptoms
c. Brandon- all other cervical range of motion created slight neck discomfort but there was no specific reproduction of multiple areas of symptoms like with front L quadrant; L rotation, SB, and flexion were limited more so than other cervical movements but slow and guarded for all directions (did not do a great job at quantifying any of them specifically)

4) Barrett- I forgot to add on there that day 2 I did upper cervical UPAs to follow up upper cervical screen and headache was reproduced with R C1-2 UPA

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