Treating Two Body Regions

[Tyler France]

Hey everyone,

I’ve been having some patients with similar presentations come in to our clinic recently and I am not having the outcomes I wanted, so I figured I would ask for some input here.

Pretty commonly, I’ve been seeing UVA students coming in with complaints of cervical and lumbar pain (usually lower cervical and upper lumbar) that is aggravated by prolonged positioning while they are studying. All of them present with decreased motor control in both regions and with overall postural dysfunction that seems to be the root cause of their symptoms. Other than addressing the common factors between them, including thoracic mobility, postural exercises and ergonomic assessments, I have tried to treat them all based on their individual impairments. However, none of them are progressing as quickly as expected and I believe this is largely due to me attempting to focus on both body regions within each treatment session. If there was one area that was more bothersome to each patient, I would focus on that first and then treat the other region later on. Unfortunately, most of them say that they are equally limited by both areas. As a result, I have been spinning my wheels trying to treat the cervical and lumbar spine within each session.

I was wondering if you all had any tips and tricks on how to proceed when treating patients who are equally limited by two separate body regions.

Hope you all have a great weekend!

[Aaron Hartstein]

Hi Tyler.
When reading this, I thought you were going to comment about the chronicity and/or sensitization of these patients. If there is an issue of sensitization here (which I realize might not be the case at all), than consider that sometimes additional areas will become symptomatic as well and that your treatment might have to include elements of TNE/PNE in addition to treating the primary or source of initial symptoms (top down and bottom up treatment, according to the TNE/PNE folks). However, if this is not the case (and it sounds like it may not be), I agree that focusing on the worst area and impairments that we know connect the two regions (thoracic spine) may be more beneficial than chasing two separate pains in one session, manually. Your exercise selection, on the other hand, can be the link to treating both simultaneously. If you were to test their extensor endurance (like Rusty Smith suggests), you might very well provoke both symptoms, especially considering their is an endurance component to their complaints. If this is true, than your exercises could focus on the deep longitudinal sling and incorporate both areas at the same time. This way, your manual therapy techniques may only need to address the hypomobilities in the thoracic spine and ribcage while your more specific ther ex, considering the type of contraction they need (isometric and against gravity), treats the motor control component of the other areas. Just my 2-cents.
Aaron

[Tyler France]

Aaron,

Thanks for the insight! As far as chronicity goes, all four of the patients I had in mind for this post began experiencing symptoms within the first two weeks of class starting. Only two of them had experienced neck or low back pain in the past. None of them seem to have any issues that would lead me towards anything non-mechanical. They all show deficits in prone extensor endurance however. I certainly think that I need to address the deep posterior sling more in my future sessions in order to kill two birds with one stone rather than trying to treat them as separate issues. I find myself becoming hyper-focused on treating whatever region is bothering them more in that specific session than using a more global approach which would likely be more effective.

[Michael McMurray]

Tyler – Think “Functional Patient Centered Goals” when multiple body regions. You can kill many birds with one stone, as you have them tell you functional versus pain goals; and you design functional exercise prescriptive exercises based on those functional goals versus chasing pain complaints.

Always challenging, but take a step back and keep it simple – let the patient guide your treatment.

[Katie Long]

Hi Tyler, I have a somewhat similar case I am working with in the sense of struggling to manage two body regions. My patient had a fall a year ago and then experienced CRPS leading to disuse of the entire right UE. He has severe mobility and strength impairments of both the hand and shoulder now that the CRPS has cleared up some. He is most concerned about his hand, stating that “the shoulder will get better once I get it replaced”. However in the evaluation, we discussed working on both regions and came to the agreement to treat one body part each session and alternate between the two. While this is only one case I have personally been responsible for managing, I think discussing the plan of care to address both body regions independently with each visit was successful for me. That way when he comes in on Monday, he knows its a hand day and when he comes in on Wednesday, its a shoulder day. Maybe try something like that with your patients? Good luck!

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