Patient Case Discussion

[Jennifer Boyle]

Hey Everyone! I have a patient right now that I am having some trouble with and was looking to see what you all thought.

69 y/o male Audiologist who was helping his work office move locations. He was lifting heavy boxes when he heard a “snap” in his neck followed by immediate onset of pain on the left side of his neck but continued to load the boxes into the car. The next day he had burning pain down the L side of his neck, lateral shoulder, lateral arm and lateral forearm. In addition he described contralateral foot numbness “like it was falling asleep”. He went to a series of doctors and the decision was made to perform a spinal fusion of segments C3-C5 in January 2018. After this he had a resolution of his R foot sx and temporary relief of his L arm sx but these returned soon after and have been progressively getting worse since. Came to PT 4 weeks ago.

Psychosocially:
•Pt is very worried that his job is going to fire him because of this incident and workers comp will stop paying. He has had many stressful conversations over the time I have been seeing him with his job and he noticed that his sx are typically worse during and after these events. In addition, he is worried about the surgery if it has worked or not and often asks why he is not better after the operation/ if it is safe to move.

Current status:
Aggs: Turning neck to the L (driving), Showering with water on his arm or touching his arm increases burning, sx get worse at night. He is unsure of other aggs and reports the pain has a “mind of its own” and he cannot predict when it will spike up.
Eases: Gabapentin (3), Walking at times can calm down his sx
ROM:
• Cervical: Full and pain free flex/ext, Rot: R: 60 deg pain free *L: 50 deg with L sided cervical pain and inc burning down lateral shoulder and lateral arm, Sidebend: R: 15 deg pain free *L: 10 deg with L sided cervical pain and inc burning down lateral shoulder and lateral arm
•* Shoulder: All full and painfree with the exception of L shoulder ER 70 deg and painful
•Elbow/ Hand wrist: Full and pain free

Dermatomes:
•* Hyper sensitive along L C6 neurodynamic pathway (in comparison to R UE)
• Described as increased burning with use of sharp object down the lateral aspect of his arm and forearm
Myotomes:
•All strong and painless with the exception of
o* L wrist ext – painful but not weak/ fatigable

Neuro:
•(-) Hoffman
•(-) Babinski
•(-) UE and LE clonus
•Hyper reflexive L C5, C6 and C7 in comparison to R UE

Neurodynamics:
•(+) ULTT 2b

Tx Thus far:
•T spine mobilization (Gr III-V)
•Shoulder mobilization for ER (Gr III-IV)
•STM to C6 neurodynamic pathway with muscle tacking
•Pain science discussions about what is happening and how to cope with stresses with exercise

Subjectively reports feeling better sometimes but others it feels worse then before the surgery. Objectively there have been great within session reduction of sx as per pts reports as well as objective * changes, however, there has been very little between session carryover.

1) Going along with Justin’s last journal club, how can I better address his fear of cervical motion and returning to activities like driving without the fear of messing up the surgery?

2) How would you address his concerns about how well his surgery worked and why he is still feeling the same sx as he did prior to his operation?

3) Do you think his presentation warrants a trip back to the surgeon?

4) What other interventions can I look into to help with more carry over between session?

[Justin Pretlow]

Hi Jen,
Thanks for posting – Most of my initial thoughts are probably strategies you have already tried.
In terms of addressing his fear of movement – I think I’d stick to simple, non-threatening language, over and over again. I suppose I’d hammer home the point that the surgery fixated those segments but that can easily cause irritation, increased demand on all the tissue around that area. Describing the nervous system as irritated/angry, hurt not equal to harm.
I’m out of time but will think on this and address your other questions.

[Katie Long]

Hey Jen, not exactly the same, but I had a patient who presented with peripheral sensitization following a Staph infection in his hand. He presented with fear and apprehension regarding return to bowling and playing with his granddaughter because of his symptoms. He was very confused about his symptoms and why they were so inconsistent, he also seemed to not be able to pinpoint specific aggs. We worked a lot on gradually introducing AROM/AAROM/PROM motion to the system. Elvy cervical glides in neruodynamic positioning was very effective for him, maybe these could be helpful for your patient? A lot of our focus was introducing ROM and neurodynamic mobility without re-irritating the system. It helped him a lot with confidence and fear as well to see how he was able to do something that he couldn’t do a previous week because of his symptoms.

I’m attaching some articles that I found helpful in this case.

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[Katie Long]

Here are the other 2.

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[Sarah Bosserman]

I have used Katie’s first article before and I always think of this quote with patients with central sensitization: “…education of the central
sensitization model relies on deep learning, aimed at reconceptualising
pain, based on the assumption that appropriate cognitive
and behavioural responses will follow when pain is appraised as
less dangerous (Moseley, 2003a)”. Fear seems to be a big limiting factor for him, both with exercises and in his life (fear of losing his job). Education could go a long way for this patient – which I know you have done — sometimes videos (moseley ted talk, etc) or giving him articles to read at home can reinforce the concepts you discuss and he can think through it in a lower stress environment.

[Tyler France]

Hey Jen,

I had a similar case a few months ago who had a return of her LE symptoms about a month after a lumbar fusion. In her case, she was doing a lot of extra exercises at home in addition to her HEP and I think she was probably just getting some inflammation in the area. When we worked through her exercises and educated her on not doing too much, her LE symptoms resolved. That may be something worth looking at with your patient.
I’d also recommend using the first article that Katie posted to help with patient education, I have used some of those techniques in the past and found them reasonably successful. As far as a referral to the surgeon goes, I would probably get in contact with the surgeon yourself to let them know what is going on. Depending on how long you have treated this patient, a referral back may not be necessary, but it could not hurt to open the line of communication.

[Jennifer Boyle]

Thanks guys! All great advice. I will keep you posted with progress.

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