Oct 2018 – Journal Club Case

Home Forums Journal Club Case Discussion Forum Oct 2018 – Journal Club Case

This topic contains 3 replies, has 3 voices, and was last updated by  Jon Lester 13 hours, 36 minutes ago.

  • Author
    Posts
  • #6852

    Dhinu Jayaseelan
    Moderator

    Hi all,

    Please see the attached pdf for the case information. Answer the questions, and add additional insight/questions/comments/etc to facilitate discussion. We will talk more about this patient, and the integration of research in her care, next week. Thanks,

    Dhinu

    Attachments:
    You must be logged in to view attached files.
  • #6856

    jeffpeckins
    Participant

    1) Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
    – Is she able to link the recent worsening of symptoms to a traumatic event or change in usual activity?
    If not:
    – History of cancer? Increased pain at night that can’t be changed with change in position? Night sweats? Recent unexplained weight loss?
    – Any other body regions painful?
    – Yellow flags: fear of movement, anxiety, other psychosocial factors?
    – Did she think that a specific aspect of previous PT was essential to her pain relief?

    2) Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?
    – Yes: MOI, decreased cervical flexion strength, point-tenderness/ myofascial TPs
    – No: no referred shoulder/UE pain, no dizziness/nausea, HA, etc
    – I believe she would be a better fit in the “neck pain with mobility deficits” category.
    — Central pain, limitation in neck motion, limited cervical ROM, neck pain at end ranges of AROM (however not PROM…), C and T hypomobility, motor control deficits

    3) Do you see any red or yellow flags associated with this condition?
    – Yellow: fear avoidance (not wanting to drive), multiple PT treatments, was in cervical collar for 4 weeks, “always has pain”

    4) What concerns do you have about the patient’s current presentation and previous treatment?
    – Lots of passive treatments, depending on how much exercise she did
    – Has she been given an HEP from previous PT, and if so, did she attempt that before she sought out PT again?
    – She has never completely resolved her symptoms back to baseline
    – Worsening symptoms even through there doesn’t seem to be any recent traumatic incident or reason for the increased pain (i.e, driving more often, longer work days, increase in activity)

    5) What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
    – 1st: Cervical AROM in non-painful ROM (or minimally painful if non-painful not possible) which will likely be supine
    – 2nd: Education and advice regarding the necessity for continued movement and exercise (especially aerobic such as stationary bike)
    – As quickly as possible begin including mobility and strengthening exercises, not relying very much on MT and decreasing amount of MT time

    6) Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?
    – Wouldn’t do Grade-V mobilizations due to osteoporosis status

    Additional Discussion:
    – I think determining the patient’s thoughts and beliefs about why she is in pain, why the pain keeps coming back, etc would be helpful. She seems to have some yellow flags that are concerning and likely inhibiting her recovery. I would bet that she is hyper-focused on her pain and thinks that something is anatomically wrong with her following the MVA four years ago.
    – Research has been shown that education is very helpful in patients suffering from WAD. What education would you provide this patient and how would you reassure her that she will get better? (Side note: this is assuming that we would categorize her in the WAD category, but I’m sure this is helpful regardless of categorization)

  • #6867

    Jon Lester
    Participant

    1) Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
    a. Fosamax – dosage, how long, compliance, recent inc? – Common side effect is joint/muscular pain
    b.I’d like to know more about previous PT. Why did she have to return 2x/year for 4 years? Did she have resolution of symptoms and then they came back? Or was it a financial/insurance reasons? Could give us an idea of expectations. Also what part of PT that she believed helped the most would be nice to know when planning POC.
    c.How did they rule out fracture? MOI alone would warrant an x-ray at that time (Canadian C-spine rules) but doesn’t mean we can assume one was performed. Hx of osteoporosis is concerning as well. Also, does she notice any “clunking” with cervical movements, feeling of “lump in throat” or any other subjective c/o that might indicate ligamentous disruption? MRI might be better choice in this case.
    d.Recent increase in symptoms – was there another mechanism that caused this? Or is this how her normal pain fluctuates (PT 2x/yr for 4 yrs)? Additional, seemingly minute, trauma to a previous injury could be more deleterious in someone with osteoporosis as compared to those with good bone density.
    e.How often does she receive imaging for bone density (i.e. DEXA scans)? Any changes since the initial injury? How has it trended since starting vit D and Fosamax?

    2)Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?
    a.Yes I would consider this a WAD presentation with associated mobility and motor control deficits. The underlying condition is likely WAD because of MOI with motor control impairments present (stretching of DCF causing inhibition with cervical movements), which is common with similar trauma. This improper motor control could possibly have led to compensation of the facet joint capsules to “tighten up” and limit motion via non-contractile contribution. This could possibly be why this case could fall into either the neck pain with mobility deficits or neck pain with movement coordination deficits based on how you interpret it. The objective findings show that both classifications are likely present to some degree (hypomobility + pain at Csp facets and inability to activate DCF). It’s a bit of a chicken-or-the-egg conversation and I could see both sides.

    3) Do you see any red or yellow flags associated with this condition?
    a.Fear avoidance with driving
    b.Worsening of symptoms – especially without mechanism at point of worsening
    c.MOI with hx of osteoporosis
    d.LOC at initial injury
    e.Cervical “manipulation” in previous PT
    f.Somewhat failed PT because she was unable to maintain improvements on her own (PT 2x/yr for 4 years)

    4)What concerns do you have about the patient’s current presentation and previous treatment?
    a.Current Presentation
    i.Worsening of symptoms – inc in fear avoidance
    1. Also worsening without obvious MOI – possibly more sinister implications (e.g. tumor)
    ii.Inability to activate DCF
    iii.“Worst pain 8/10” and NDI 44%
    iv. Hypomobility for B UPAs throughout all mid-cervical (not that concerning but more difficult than one sided or less levels)
    b.Previous PT
    i.Cervical manipulation in patient’s age group, with hx of osteoporosis, with fear avoidance, and MOI
    ii.Dec duration of relief (had to keep coming back to PT) – doesn’t sound like she ever got back to her PLOF
    iii.Hard to tell what helped give her some relief (heat vs TENS vs exercise etc) – also sounds like a lot of variations of passive therapy

    5)What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
    a.Manual Therapy – manual distraction because it was (+) for pain relief, but I could also promote improved joint mobility bilaterally without aggravating either side
    i.HEP – Pain-free AROM in all directions – start with NWB if WB is not tolerable
    ii.Progression – begin to mobilize both B facet joints with distraction combined with opening joint mobilizations (SB/rot) → then opening without distraction → then eventual closing to improve tolerance to closing movements (as pain permits)
    b.Exercise – tactile/verbal cueing to promote improved DCF activation via light chin tucks in supine
    i.HEP – light chin tucks over towel for tactile cueing in supine
    ii.Progression – chin tucks in upright position → upright position with arm movements → upright position with cervical movements (i.e. rotation to improve confidence/endurance with driving) → eventually add resistance that is pulling out of upper cervical flexion
    c.Pt education on how movement won’t cause pain and how it’s important to reduce her symptoms. Also could include some pain neuroscience analogies if she presents in a way that I feel like this would be helpful on her first day.

    6)Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?
    a.Cervical manipulation
    b.Cervical mobilization to promote opening/closing on one side (will cause opposite effect on other side, might be painful)

    Additional Discussion
    1)Would anyone have tested deep cervical extension endurance? I feel like this would be nice to do in someone who has pain onset after sitting >30 mins (losing battle to gravity). Maybe scapular endurance also?
    2)Who would do some form of trigger point release early on in rehab for this person? It looks like she might respond to other more mild forms of treatment but her active trigger points might respond to more aggressive forms of MT also (TDN, ischemic pressure, pinning down with active movement). Just curious to see how aggressive others are during early rehab in those with fear avoidance.
    3)Would you implement the FABQ with this patient?

    • This reply was modified 13 hours, 45 minutes ago by  Jon Lester.
  • #6869

    Jon Lester
    Participant

    Jeff – In response to your post – I agree that education would be key to her understanding her symptoms and prognosis. I would educate her on the findings that I found that were reproductive of her symptoms (hypo/painful joint mobs, +distraction/compression, dec DCF activation, etc) and how they are all treatable from a rehab standpoint. I would educate her on the length of time I would expect her mobility to improve (gradual over several weeks of directed treatment) and with her motor control/endurance (can take 6-8 weeks to have true muscular changes). My hopes would be to both have her understand that her symptoms are reproducible and treatable, but also that she needs to be an active participant in her therapy. If she was still worried about something being “structurally wrong” with her neck because of the injury, I would educate her on the negative findings that I had that would implicate this to be true (i.e. sharp purser, alar lig test, (-) CN screen). I typically only do this if they press for the information because I feel that some might be concerned that we were concerned enough to look for those things. I’m curious on other’s thoughts on this?

You must be logged in to reply to this topic.