October Journal Club Case

[Jennifer Boyle]

Hey everyone! Here is a description of my cervical patients case and the article is attached below. See you all next week for some discussion.

Subjective:
Patient is a 30 y/o female with chief complaint of R sided neck pain that can radiate up the back of her head and behind her eye. Additionally, she has R upper trap pain that can travel as far as the periscapular region on the R side. She has been experiencing these symptoms for the past two years and these episodes have been occurring intermittently every few weeks and can last up to one week at a time. The start of an episode tends to correlate with extended periods of time sitting at her work computer. Second most recent episode pt woke up with painful neck and went to the emergency room for the pain. She was given muscle relaxers that she takes when she feels the upper trap pain coming on in order to avoid a migraine and post muscle relaxer the next day the episode seems to be resolved. Most recent episode was occurring during her evaluation making it difficult to assess status without pt reporting dizzy feeling associated with all head motions. Pt answer no to all Red flag questions with the exception of feeling nausea and vomiting when the migraines progress too far. All tests and measures were performed during the fist and second visit because of the severity and irritability of the pt status during the initial evaluation.

Aggs: Sitting long periods of time, wearing a backpack or purse, sleeping on R side, looking at bright lights
Eases: Muscle relaxers, ibuprofen, heat, ice and stretching

Pain: Best: 0/10 Average: 4/10 Worst: 8/10

Severity: Mod-Max (Pain 8/10 at worst with moderate interference with ADLs and work tasks)
Irritability: Mod – Able to reproduce symptoms with asterisks (listed below). Once symptoms were provoked they took the rest of that day and muscle relaxer to subside.
Nature: Mechanical/ somatic
Stage: Chronic
Stability: Worsening

Objective:
– Shoulder screen: all full and pain free motions
– (-) VBI screen
– Active ROM:
*Cervical: Flexion 30 degrees, Extension 40 degrees, Sidebend L: 20 R: 25 Rotation L: 30 P! R: 30 (limited by apprehension to turn secondary to dizzy feeling, did not get to true end range)
– Upper cervical flexion: empty end feel with pain on R side
– Resisted testing: Not tested secondary to acuity of symptoms
– Accessory movement: Hypomobile R AO with pain , hypomobile C1-C3 with pain on R, Hypomobile CT junction C7-T3
– TTP- R AO jt, central and unilateral (R) P-A C2-C3, central and unilateral (R) C7-T3 R upper trapezius, R SCM, cervical paraspinals
– Special Tests: (+) Flexion rotation to R and L both producing R UC pain
(+) Compression (+) Spurling (L sidebend) (-) Distraction
– Neck Disability Index: 18%

Primary hypothesis: Upper cervical: Cervicogenic headaches/ dizziness caused by hypomobile segment at R AO joint. CT junction: C7-T1 R facet dysfunction.

Asterisks:
* UC flex with over pressure
* Pain with R P-A unilateral glides to AO jt with head in 30 degrees
* Pain with R transverse and unilateral glide of C7-T3
* L cervical rotation with over pressure
* Flexion rotation to the R with R side neck pain

Treatment:
Day 1:
– Gr III unilateral P-A R AO Jt and C2 in 30 degrees of R rotation
– Gr II/III central P-A upper T-spine
– STM to cervical paraspinals and upper traps
Day 2:
Progression of day 2 was prompted by marginal decrease in symptoms between treatment 1 and 2. Implication of Dunning article during this treatment yielded within session decrease of asterisks symptoms and followed the progression below.
– Gr V Supine T-spine manipulation
– Gr V CT junction manipulation
– Gr III unilateral P-A AO and C2 in 30 degrees of R rotation
– Gr III transverse and unilateral to C7-T3

HEP:
– Chin tucks with 10 sec holds
– Upper cervical (AO/C2) snags
– Upper trap stretch
– Pectoral stretch

Future components to investigate:
– Cervical endurance tests for flexion and extension

PICO:

In patients with cervicogenic headaches, does cervical and thoracic manipulations reduce headache intensity and frequency more than a treatment plan consisting of mobilization and exercise as indicated by their numeric pain rating scale?

Discussion Questions:

1) Although this article talks about the efficacy of performing manipulations to effects a dysfunction at C1-C2, do you believe this patient with an AO hypomobility deficit could still benefit from this technique even though she does not truly fit the article criteria?

2) This article speaks about using the C1-C2 manipulation on the R and L side of the joint even if the symptoms are unilateral. What could be the clinical reasoning behind performing bilateral manipulation while a patient presents with unilateral symptoms?

3) This randomized control study investigated the effects of manipulations without exercise vs. mobilization with exercise in the treatment of cervicogenic headaches concluding the manipulation group had statistically significant reduction of symptoms over the mobilization with exercise group. Although both treatment groups made improvements, are there any clinical patterns in this population that would make you choose one technique over the other?

4) Manipulations, mobilizations and exercise have all been deemed effective in the treatment of cervicogenic headaches. This particular study yielded results supporting manipulations as the preferred method of treatment for most successful outcome. What could be the mechanism behind these results?

Attachments:

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[Katie Long]

Hey Jen, thanks for posting! This case and article was very helpful for me, as I just saw a patient with cervicogenic headaches and myofascial pain in the cervical region this past week.
I think that your first question is a good one, and I think I consider the use of the C1/2 manipulation even though your patient has OA hypomobility similar to our discussion at the last course about utilizing thoracic manipulation for cervical pain as a way to “gain access into the system”. I also think it is realistic to have some effects occurring at adjacent segments when we are manipulating, so a C1/2 manipulation could potentially benefit one with a OA dysfunction. Getting into your second question, I used manipulation with my patient to affect the cervical myofascial tissue in the surrounding area, so that could be part of the apparent benefits of the bilateral manipulation as well.
My only issue with this article is that I wish that the manipulation group also got exercise (or that the mobilization group didn’t get exercise), I feel that it is a little bit of an unbalanced comparison. I am also wondering what your opinion on patient education and dependence/independence based on their results. From this study’s results, it appears that we could manipulate our patients and then send them out the door and they would still get better than those who were mobilized and got exercises. I am wondering if the results of this study could foster dependence from our patients and less self-efficacy in their symptom management. I am curious about the nature of the conversation that you had with your patient regarding manipulation, its effectiveness, and the role of exercise (if any)?

[Tyler France]

Jen, I think this article is great and contains some good information that we can use with patients that we see frequently.

Even though this article utilized C1-C2 manipulations, I still think any upper cervical manipulation could be beneficial for your patient. Over the past couple of years, I have seen conflicting information about the importance of manipulating a specific segment to achieve symptom reduction versus manipulation in general. Since we are seeking to achieve a more global pain modulating effect with our manipulations, do you think that you’d have to manipulate the OA joint specifically to achieve the desired result, or would any cervical manipulation suffice?

As for your second question about performing manipulations bilaterally, my thought would be that they are just trying to enhance the neurophysiological effects of manipulation and they can circumvent the refractory period of the side they already manipulated.

As for your third question, my biggest complaint with the article is that I cannot specifically incorporate it into my practice because I would always pair the manipulation with exercise. When looking at the nature of your patient’s cervical pain, it is likely that there is an underlying dysfunction (motor control, etc) contributing to the issue. By manipulating her, you may reduce her pain temporarily, but you aren’t really addressing the issue that is causing it in the first place. I think the article would have greatly benefitted from having a long term follow up to see what percentage of each group had another episode of cervical pain and HA.

[Justin Pretlow]

I think the results of this study are applicable to your specific patient. Similar to what Katie and Tyler said, manipulation of a certain segment is likely to have some effect on adjacent levels of the spine. The avg. age of 35, 4 plus years of headaches, and the frequency of HA are all similar to your patient.
Regarding your second question, I think unilateral symptoms can often be attributed to movement dysfunction of the contralateral side or both sides. This would give me reason to consider performing mobs or manipulation to both sides, depending on the specific patient.
I’m not sure how to answer question 3.
Per question 4, one possible mechanism could be a positive psychological effect regarding the expectations of the treatment. Perhaps patients who received a manipulation and heard that gratifying pop felt like they were receiving a treatment that was fixing their problem. And the idea of receiving a passive treatment and not having to work at it between visits could help frame the treatment in a positive light.

[Sarah Bosserman]

I think that your patient fits the criteria in a number of ways in terms of chronicity and symptom referral. To the point a few others have made, I think manipulating adjacent segments can still achieve the analgesic/neurophysiological effects we are looking for.

I think this article was helpful in that it highlighted how useful manipulation can be for those who are in a lot of pain. At the 1-week follow up, patients in the manipulation group had a significant decrease in pain comparatively, which could be beneficial for patient buy-in and allow for other treatments earlier on. Tyler mentioned addressing the underlying issue with exercise following the manipulation. I agree that solely relying on passive treatments does not empower the patient and give them tools for self management in the future. I liked this study, but I would have also liked to see if exercise + manipulation would have yielded improved long term results. Furthermore, the article did not discuss the conversations and education that took place between patient and therapist that could also had an affect on patient expectations. I would also be curious about the conversations you guys have with your patients when discussing the role of both manual therapy and exercise in their treatment?

[Jennifer Boyle]

Hello everyone!

I just wanted to update you all on how the treatment session with the patient I presented on went yesterday. Upon arrival she expressed that after the last session she was having tingling down B upper extremities, neck pain, nausea, vomiting and spinning sensation. She stated that she went to sleep after this and woke up the next day feeling much better than she has in a long time. She proceeded to tell us that she believes after performing our treatments she was a bit stressed out about everything we were trying and this may have enhanced her symptoms that following night. Once she realized that next day she was feeling better her symptoms remained at a minimum for the rest of the week. After she told us all of this, I took it as the perfect window to start talking about her coping mechanisms as per suggestions during journal club. We opened this encounter with asking about how she typically takes time for herself and how she distresses and immediately she was very receptive to this question. She started to cry and admitted she did not have time for herself nor did she have any mechanisms to help her distress. We used this as a perfect opportunity to develop patient rapport as well as explain to her that this stress could be adding to her pain. We were able to help her connect the importance of physical and mental health and how this may be negatively impacting her recovery. We made sure that she understood what we are doing is just a small part of rehab and that to treat the whole person we need to also help her develop her stress outlets. As a result, we reached a conclusion of her joining yoga and coming into her therapy sessions early in order to work out for 20 minutes as her means of distressing. As for her manual treatment we let her pick the aspects she felt were most beneficial to her in order to let her take control of the situation. Gr V T-spine manipulation was picked from the last session with a decrease in tenderness to palpation to her upper trap post manipulation. I feel that yesterday’s journal club helped me an incredible amount in guiding my treatment session to look into her psychosocial presentation and not just her physical presentation to treat the whole patient and not just part.

[Myra Pumphrey]

Jennifer – You have no doubt just posted a very important aspect of her care which will help optimize her results. However, I want to make a couple points. It is very helpful to get in the habit of asking on day 1, specifically, where pain is NOT and checking it off on your body chart. For her, I would have subjectively ‘cleared’ upper extremity symptoms and symptoms in the face and chest. THEN, when they walk in and tell you that they have tingling in the arms, you have a quick reference that you did in fact ask and they denied symptoms in these places. Now that she is describing tingling in the arms, you need to ask a specific pattern to help you with your clinical reasoning.

Now that her status/symptoms have changed, you have more in your clinical reasoning chart. Even if your neuro exam was negative previously, would you repeat? If you never did a neuro screen, would you do one now? What would you include in your exam? You mentioned in your presentation that you had done upper cervical instability testing. Which tests did you do and what was the outcome? This is a good time to be analytical about ANY influence, psychosocial AND otherwise, that may have contributed to the significant regression, then improvement in her symptoms.

Remember, even with strong psychosocial components, you often have musculoskeletal and neurological components that may be very significant…they may even be feeding the psychosocial aspect of their presentation. Make sure you clear potential yellow/red flags to ‘prove’ your hypothesis of their significance or lack of significance.

[Michael McMurray]

Great job

What a great learning case – continue to take aspects of this presentation and your treatment successes and build upon. That communication and treatment decision making involving the patient preferences/priorities are ART of what we do.

See ya Saturday.

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