Weekend 2 Case

[Michael McMurray]

Below is the information for the case that will be presented. Please read the information, post questions and comments. Read the questions at the end of the case and post thoughts and answers and be ready to discuss at the beginning of Saturday.

Chart Info:

34-year-old female
– 9/25/18 – Eval
– Occupation: English Literature PhD student, works also in library sciences
– Reason for Referral: “chronic pain syndrome affecting neck, shoulder, head/migraines”
– Medications: duloxetine
– NDI: 54%
– Quick Dash: 43% (disability score), 16 (work), 15 (yoga)
– Body chart

Subjective:

MOI:
– No specific mechanism, chronic neck pain for 14 years, migraines since she was 18 y/o, she states migraines have contributed to decreased physical activity – migraines are not primary complaint

Chief complaint: pain
Location and nature:
Left posterior cervical region that wraps around to anterolateral neck – can have bilateral
“spasm pain”
Suboccipital pain – bilateral
“tendons pulling pain”
Left chin / ear pain
“difficult to describe”
Left temporal region
“headache pain”
Left rhomboid / levator region
“spasm pain”
5th digit
“pins and needles”
Lateral/posterior elbow
“pins and needles”
Aggravating factors:
Sitting (worst)
Driving (mostly the sitting aspect)
Cold weather
Supine
Relieving factors
Staying active – movement
Hot yoga
Keeping hands low on steering wheel while driving
Migraine medication helped from age 18-25 with medication, medication effects have diminished
Pain
Now: 5/10
Worst: 10/10
Best: 2/10
Severity: Mod- severe (my judgement)
Irritability: Mod (my judgement)
Other subjective:
– Left handed
– Previous PT treatment – not consistent, acupuncture -didn’t help, botox (anterior/lateral/posterior head) – helped dull pain initially
– Denies: speech/vision/balance/previous injury/previous surgery/migraines with aura or nausea
– Occupation: sits for 60 minutes at a time for 5+ hours/day for 5 days/week + weekend studying/working
– Patient goals: decrease neck pain so that she is able to get out of the house more, drive with decreased pain and go hiking

Objective (asterisks):
– Posture: forward head, rounded shoulders, slouched
– ROM: symmetrical and normal A/PROM with end range pain: flexion (suboccipital p!), protraction (suboccipital p!), retraction (decrease suboccipital p!), L rotation (SCM region tight), R rotation (posterior neck tightness), L SB (OP p! local in neck), R SB (OP p! local in neck)
– Neuro: diminished left C8 dermatome, symmetrical/normal with other dermatomes and myotomes, DTR, and UMN
– Palpation: TTP: suboccipital, levator insertion left, upper trap left, SCM origin left, rhomboid
– Joint: C2/3 PAVIM left increased left ear pain, upper to mid cervical PIVMS had decreased right rotation, CPA hypomobile painful, UPA left hypomobile painful
– Special tests: Spurling’s, distraction, ULTT 1 – all were painful but not her same pain; flexion rotation (-), CFET: 25 sec

Based on the brief information presented:

1. What are your top three diagnoses based on the subjective information? (ranking order)

2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)

3. Based on your diagnosis, how would you tell this patient your findings?

4. What HEP would you give the patient on the first day?

5. Obviously I did not test everything on the first day. What other subjective questions and objective tests would be helpful to know regarding this patient case?

[Michael McMurray]

1. C8 Nerve Root/Radiculopathy, Upper Cervical Joint Dysfunction, myofascial pain

2. Upper Cervical Joint Dysfunction potentially causing cervicogenic headache. Reasoning: C2/3 PAIVM increased complaint of left ear pain, Cluster of tests for radiculopthy didn’t reproduce her CC, protraction pain (upper cervical closing joints), retraction diminishes pain (opening joints), prolonged sitting aggravates symptoms

3. I would tell my patient she’s been a student since these symptoms came on and likely spends a ton of time reading with poor posture. We were partially able to reproduce symptoms with poor cervical posture (forward head/protraction) and her symptoms were relieved with good posture/retraction. I would explain facet referral pain for the upper cervical vertebrae and how this irritation can easily cause cervicogenic headaches which is another complaint of hers. I’m not fully able to explain the C8 distribution of symptoms but she may also have lower cervical facet irritation and with a 14 year history of chronic pain I would explain the longer you’re in pain the more pain tends to refer elsewhere and cause secondary symptoms.

4. Cervical flexion strengthening, I personally also tell my patients to set an alarm on their phone as a “posture check”, self myofascial release to suboccipitals and upper traps/levator, stretching to same muscles

5. I was unsure about what the statement regarding spurlings, distraction, and ULTT being painful meant and if that means a positive finding than I would likely be leaning more towards radiculopathy but if they’re negative I’m sticking to joint. I’d like to know how often her C8 type symptoms are present and whether or not spurling created a local neck pain or more of a “pins and needles” pain as this would also be crucial information. I’d like to know her thoracic and shoulder mobility because with limited thoracic extension she may be extending more through her cervical spine causing more of a C8 compression or facet irritation throughout the cervical spine. I would ask the patient if her arm symptoms seam related to her neck pain and whether there is a pattern between the two.

Overall there’s still some uncertainty as to whether or not this is all coming from one issue or whether she potentially has multiple issues. It’s possible she has upper cervical dysfunction causing cervicogenic type headaches and corresponding myofascial impairments and at the same time has C8 irritation from lower cervical dysfunciton. I don’t want to hang my hat on one set of special tests but knowing in more detail the findings of the ULTT and spurlings would give me better insight as to whether this is more radiculopathy or joint related.

[Michael McMurray]

1. Lower C/S facet dysfunction, Upper cervical facet referral, TMJ
2. Lower C/S facet dysfunction → pt’s sxs started approx. 14 years ago. At this time, we are unsure if a traumatic event happened during the time of onset which may be contributing to the psychosocial aspect of her sxs. Facet irritation can lead to under activity of muscles such as the deep cervical flexors, and cause tightness of the suboccipital muscles, upper trap, and SCM. Over time, tightness of these muscles could effect joints both proximal and distal to the initial location.
-4/4 of the C/S radic cluster appear to be negative
-Symptoms began at a young age and have not improved → indicating psychosocial involvement and chronic hyperactivity of various muscles
-Both Upper cervical and lower cervical joints are limited and reproduce pain
-Retraction reduced symptoms, indicating that posture is influencing symptoms
3. I would first address the pt’s posture, and discuss how her every day posture may be worsening her symptoms. I would provide her with positional modifications and encourage rest breaks throughout the day. I would ask further questions to determine if there was any traumatic incident that occurred around the onset of her sxs 14 years ago, as this may be influencing her sxs → If this is the case, I would incorporate pain neuroscience education on day 1, emphasizing that tissues are not damaged from and event that happened 14 years ago. I would then explain the reasoning for referral and “spreading” of sxs, and why she has pain into her anterior neck and ear region.
4. Postural education, activity/positional modification, deep cervical flexion in supine, cervical rotation in supine, scapular retraction
5. Previous traumatic event around the initial onset on sxs, why previous treatment was not successful, what types of treatment did she receive in previous PT. Does the patient have pins and needles on just the left? Has she been dropping things recently?

[Michael McMurray]

1. What are your top three diagnoses based on the subjective information? (ranking order)
a) posture-driven upper cervical jt dysfunction with specific consideration given to A/A jt due to HA pattern
b) myofascial pain from SCM (ear and chin pain, HA), suboccipitals (HA), levator strain
c) TOS/brachial plexus irritation from poor posture, or other separate elbow/arm issues since pt is L-handed

2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
a) upper cervical jt dysfunction: poor posture crunching upper cervical facet jts, PPIVMs tight and PAIVMs reproduced ear pain, retraction reduces suboccipital pain
b) myofascial pain from SCM (ear and chin pain, HA), suboccipitals (HA), levator strain
c) TOS/brachial plexus irritation with distal nerve symptoms since ULTT, Spurlings, and distraction did not reproduce or alleviate concordant pain

3. Based on your diagnosis, how would you tell this patient your findings?
Use the spine model for demonstration of facet jt irritation and how retraction reduces pressure through upper c-spine, bowling ball on a popsicle stick analogy to explain strain in posterior neck musculature, emphasize posture and correlate increase in symptoms with more time seated in poor posture.

4. What HEP would you give the patient on the first day?
-possibly self-massage with 2 tennis balls in a sock to upper cervical region depending on patient’s understanding/ability
-upper cervical nods & neck retraction — probably in seated since supine is uncomfortable, or supine with more pillows to elevate head to comfortable position; emphasis on small and gentle motions so as not to irritate chronically tight and irritated tissue
-try either heat or ice at home depending on level of irritation following self-massage and ther ex — pt preference indicates heat works better for her, but with pain >4/10 would encourage her to use ice

5. Obviously I did not test everything on the first day. What other subjective questions and objective tests would be helpful to know regarding this patient case?
-scapulothoracic stability: middle/lower trap and serratus ant strength
-ant chest muscular tightness — pec major and minor?
-neuromuscular control: can she perform scap retr?
-thoracic spine mobility
-elevated 1st rib?
-scalene tightness?
-check arm for myofascial irritation of common hand/wrist flexors/extensors

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