Weekend 2 Case Presentation Details

[pbarrettcoleman]

Hello:

See attached file for the information about the cervical case for next weekend. Thanks!

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[Taylor Blattenberger]

1. What are your top three diagnoses based on the subjective information? (ranking order)
1- Cervicogenic headache – upper cervical origin
2- Cervical myofascial – Upper trap strain
3- Lower cervical facet arthropathy

2. Using your number one differential, what would you expect to be (+) during the objective exam to support your hypothesis?
-Upper cervical APR (chin tuck/poke) (+) for head pain
-CFRT (+) for ROM loss, possible pain provocation
-Upper cervical accessory motion loss, and pain provocation

3. What is your top diagnosis based on the objective information and why (asterisk
signs/symptoms)?
-Multi level facet arthropathy involving the upper and lower cervical spine.
-ROM loss, pain and stiffness with accessory movements, no radiating symptoms
-Two separate issues because no single movement provoked both symptoms.
-Upper – CFRT, C1-2 PA’s provoked symptoms
-Lower – Painful and stiff lower cervical PAMs, reproduction of lower pain with these tests

4. What Manual therapy and HEP would you give the patient on the first day?
-MT – C/S CPA C5-7 GrII-III (Low irritability so no reason to avoid the specific area, and other segments were also painful so irritability would not likely change.
-HEP – Chin tucks – limited endurance, + isometrics for analgesia

5. is there something that doesn’t sit well with you in either subjective or objective? If so, what other subjective questions and objective tests would have been helpful regarding this patient case?
-I didn’t find anything concerning in the red flag questioning or PMH. Given the “MOI” and some of the aggs and eases I would have liked to see how resisted testing of the neck felt to assess for myofascial involvement.

[Steven Lagasse]

1.) Top 3 diagnoses based on subjective
-Cervicogenic HA
-Myofascial referral
-Spondylosis

2.) (+) on objective
-CFRT
-Upper C-spine CPA/UPA

3.) Top diagnosis after subjective and objective
-Cervicogenic HA
Why?
-Cervicogenic HA is my primary hypothesis because of the positive CFRT
Additionally, reproduction of symptoms with upper c-spine CPA/UPA also recreating his symptoms and are most comparable

4.) What HEP? What manual therapy?
HEP:
Supine cervical rotation on a pillow in symptom-free ROM
C1-C2 Snags (supine if not tolerate in sitting)

Manual Therapy:
C1/C2 CPA/UPA’s to tolerance; Grade I/II if unable to tolerate Grade III

5.) Something else?
-The fact that he is experiencing HA bilaterally does make me feel there may be another component to this. Potentially something myofascial in nature? I would enjoy seeing sitting vs. supine cervical rotation. I would also enjoy seeing how unweighting his shoulder girdle(s) affected his symptoms.
-The fact that this patient was seen by neuro and ENT allows me to feel more confident something nefarious is not looming

[awilson12]

1. What are your top three diagnoses based on the subjective information? (ranking order)
– cervicogenic HA (upper cervical facet referral)
– muscular referral- upper trap
– mid cervical disc/facet

2. Using your number one differential, what would you expect to be (+) during the objective exam to support your hypothesis?
limited and painful left rotation, (+) CFRT, HA reproduction with C1-2 UPA

3. What is your top diagnosis based on the objective information and why (asterisk signs/symptoms)?
I feel like there are two things that contribute to this patients symptoms:
1) CGH because (+) CFRT and pain with LC1-2 UPA
2) lower cervical facet dysfunction (C5-7) because pain and limitations with SB, rotation, and extension, and pain reproduction with C5-7 CPA

4. What Manual therapy and HEP would you give the patient on the first day?
I would either choose upper cervical or mid/lower cervical to address first and then assess efficacy of that treatment before adding in other techniques; so for starters lets say I will go with upper cervical
manual- upper cervical UPA Gr II-III for symptom alleviation and mobility (low irritability but can progress or regress based on tolerance)
HEP- C1-2 SNAGs

5. Is there something that doesn’t sit well with you in either subjective or objective? If so, what other subjective questions and objective tests would have been helpful regarding this patient case?
I would like to know more about PMH as some non-msk differentials were lower on my list; with muscular referral being on my differential list I would want to add in palpation to rule in or out myofascial contribution; even though the patient presented with bilateral neck pain UPAs at levels that reproduced comparable pain might give some good information in terms of mobility and pain for some insight into treating

[helenrshep]

1. What are your top three diagnoses based on the subjective information? (ranking order)
1 – cervicogenic headache
2 – cerivcal facet impingement (mid cervical)
3 – motor coordination issue

2. Using your number one differential, what would you expect to be (+) during the objective exam to support your hypothesis?
Tenderness/higher tone (tissue restriction) in suboccipitals, hypomobility of upper cervical segments, pain pattern (behind eyes, over head) reproduced with palpation of suboccipitals, decreased deep neck flexor endurance (low score on test), CFRT positive

3. What is your top diagnosis based on the objective information and why (asterisk signs/symptoms)?
CGH because of + CFRT and reproduction of pain with upper cervical CPA/UPA. I think there may be a secondary motor control deficit due to the deviations seen with mid cervical movement, subjective findings of pain with turning head and doing yard work (requires muscle coordination and stability) and weakness of deep cervical flexors

4. What Manual therapy and HEP would you give the patient on the first day?
Treat upper cervical restrictions with UPAs and CPAs GII/III
Mulligan rotations – cervical rotation with towel
Supine chin tucks with hold
Suboccipital release with tennis ball

5. Is there something that doesn’t sit well with you in either subjective or objective? If so, what other subjective questions and objective tests would have been helpful regarding this patient case?
I would have done more muscular palpation to assess tissue tone and possible referral (as Anna mentioned too). I would look at resistive testing of the cervical spine as well as compression/distraction. Does passive testing yield more ROM – either seated or supine? I may also want to know more about the TSA to see if continued deficits in strength or mobility from that surgery are contributing to his symptoms.

[Michael McMurray]

Awesome job! I am not at all envious of you being the first to present but so far it is looking good. I look forward to hearing the rest of the case.

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

1)Cervicogenic HA (Upper Cervical facet dysfunction)
2)Cervical muscle strain (SCM?)
3)Lower cervical facet dysfunction with referral

2. Using your number one differential, what would you expect to be (+) during the objective exam to support your hypothesis?

(+) CFRT L compared to R
(+) PPIVM C1/C2, L more limited than R (d/t rotational deficits), Possible tenderness L compared to R, Possible referral of HA
(+) PAIVM, L more limited than R (d/t rotational deficits), Possible referral of HA
Limited cervical extension, increase pain

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

1) Cervicogenic HA d/t cervical joint dysfunction
-L UPA of C1 and C2 relating to p2 with HA
-(+) L CRFT
-p1 with B SB,B rotation, and extension (facet in nature)
-p1 with CPA C%/6/7 (facet in nature)

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

Manual therapy

-PAIVM to C1/C2 and other segments with decreased mobility
-STM to suboccipitals, UT, LS, SCM (if shortened)

HEP

-Education – posture, exam findings, prognosis
-Cervical rotational SNAG
-Cervical extension SNAG
-Chin tuck 3-5s hold 3×20 (improve endurance/progress as tolerated)
supine->sitting->sitting (with functional shoulder movements)
-TB row with chin tuck

5. is there something that doesn’t sit well with you in either subjective or objective? If so, what other subjective questions and objective tests would have been helpful regarding this patient
Case?

One thing that I would ask as far as irritability goes, is how long does it take for symptoms to dissipate. I see that you have irritability as minimal and symptoms ease with massage instantly but do symptoms persist for long periods of time otherwise. Especially since he is only able to drive for 15 minutes currently.
Objectively did you find anything palpation-wise as far as soft tissue goes? Any increased muscle tension, spasms, trigger points, etc? With relief coming from his spouse’s massage, I would expect some potential soft tissue involvement.

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