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Please see attached for patient case for weekend 4.
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1. What are your top three diagnoses based on the subjective information? (ranking order)
– discogenic referral
– extensor muscle strain/pain referral
– facet referral (gapping)
2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
– possible disk referral, neurodynamic limitations (dural resictions), and associated ES muscular guarding
3. What subjective and objective information do you feel is missing and would have been helpful to assess with this
patient?
– quadrants for cervical spine
– quadrants and H&I testing lumbar if applicable
– prone lumbar rotation to identify level
– DTRs for UE for comparison
– deep breath for Tsp
– upper cervical ligamentous testing
– I would probably take myotomes/dermatomes because of pain extending throughout entire spine even though it does not extend past AC joint or gluteal fold.
– maybe repeated motions based on pt age and presentation
4. How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this patient regarding prognosis?
– Indicate positive findings to support hypothesis and ensure that pt understands that you were able to reproduce her symptoms with clinical tests. Also ensure that she understands that this follows a clinical pattern and is treatable. For further reassurance in regards to prognosis, I would make her aware of any (-) signs that were found in the exam that would improve her prognosis ((-) myotomes/dermatomes, (-) ligamentous testing, (-) crossed leg SLR sign, etc).
5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie regarding patient education, manual therapy techniques, therapeutic exercises, etc.
– Target Tsp hypomobility to work on neurodynamic limitations – manual techniques and HEP to match if possible. Repeated motions if applicable and helpful based on pt age and presentation. Could add in upper lumbar mobilization if tolerable early on. Attempt some form of mild nerve gliding with little volume early on and add to HEP based on response over a week or so. I would progress her into some form of encouragement of lumbar mobility as pain lessened to avoid fear avoidance and re-integration of full movements in all planes of motion to be able to play with daughter. That would be where I would start at least. -
1. What are your top three diagnoses based on the subjective information? (ranking order)
• Disc referral
• Muscle strain
• Visceral referral
2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
• Disc referral → pt’s sxs are worse with flexion and return from flexion. She likely does not have a radiculopathy based on her presentation; however, she might have neurodynamic restrictions, resulting in the shoulder symptoms with the seated slump test.
3. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient?
• Assess BP and HR to R/O AAA → unlikely; however, pt does complain of diffuse pain and sxs worse with exertion
o PMH of HTN, hyperlipidemia, etc for AAA
• L/S quadrants
• Prone torsion test to assess for potential disc lesion
• C/S quadrants
4. How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this patient regarding prognosis?
• The pt’s previous history of an MVA is concerning. She likely has underlying psychosocial factors that may be contributing to her symptoms, which will likely effect her overall prognosis.
• I would explain to findings of the exam to the pt, and the likely structure at fault. Many structures are likely involved due to the “trauma” of the accident. I would educate her on the general rehab process and her plan of care with PT. I would also educate her on her prognosis. Densensitization will likely be incorporated in the future; however, it might not be implemented on day 1
5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie regarding patient education, manual therapy techniques, therapeutic exercises, etc
• IF the pt was hypersensitive to touch, I would implement pain neuroscience education, to educate her on her symptoms and their severity, or more so, lack thereof
• I would likely start with general TrA and multifidus activation, and would avoid rotational or opening mobilizations
• Start with STM to decrease tissue sensitivity → then add Grade I, II CPAs if tolerated
• Gradually progress MT and NMR interventions
• I would likely add functional interventions such as squatting soon on in the program, to assist in decreasing any potential fear of movement -
What are your top three diagnoses based on the subjective information? (ranking order)
– Myofascial strain of posterior thoracic and lumbar musculature
– Local discogenic pain thoracic, lumbar or cervical
– Dural/neural irritability in thoracolumbar regionWhat is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
– myofascial strain of thoracolumbar region with potential clinical instability of lumbar spine. The patient has inconsistent pain symptoms at this time that would be consistent with discogenic or facet related pain. The reason I think it is more myofascial pain is because the patient has pain in multiple directions, increased hypertonicity/guarding, improves with posture change, active hip extension is painful but not passively, tender to palpate soft tissue, deep ache, limited trunk movement with movement. I think there might be an underlying clinical instability based on hypermobile and painful lumbar segments but would probably be hard to tell at this point.
3. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient?
– Any imaging? If so what kind.
– Fabq ?
– who gave her the lifting restriction?
– cranial nerves
– upper cervical ligamentous stability
– lower cervical pavim or PA’s
-rib spring
-what is her current stress level and stress level at work or home
-prone instability test
-scapular mobility / strength
-lumbar or thoracic resistive testingHow would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this patient regarding prognosis?
– I would say something along the lines of: you have had a couple of traumatic events within a short amount of time, and it is normal to have pain afterwards, based on my exam there doesn’t seem to be anything too concerning with red flag symptoms and that your back is strong, at this point your muscles are very irritable, which is normal after an injury as they try to protect the area, but now the muscles are still very tight and get irritated when they are stretched like when your bend forward to tie shoes or slouch.
– I might have concerns with emotions and fear and how that might limit progress. However, if everything for red flag is negative, then I wouldn’t have any major concerns.5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie regarding patient education, manual therapy techniques, therapeutic exercises, etc.
– I would focus on decreasing her pain levels with either light movement through both lumbar and thoracic regions (cat/camel or child’s pose), and add manual massage or light mobilizations to calm the system down. Gradually progressing towards her work/home related goals
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1. What are your top three diagnoses based on the subjective information? (ranking order)
• Myofascial strain
• Disc referral
• Facet referral
2. What is your top clinical diagnosis based on the objective information and why?
• Myofascial strain
i. Pain with all planes of lumbar motion
ii. Inc muscle turgor bilat
iii. lack of discogenic referral pattern
iv. pain w/ active hip extension but not passive
3. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient?
• Subjective – screening questions for possible concussion even with denial of hitting head – due to two MVA within a month, HA, dizziness, nausea, light sensitivity, sound sensitivity, loss of concentration?
i. Sleep disturbance?
• Objective
i. Repeated motions?
ii. Cspine quadrants
iii. Lspine quadrants
iv. Cspine ligamentous testing
4. How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this patient regarding prognosis?
• I would use the findings from the objective and subjective exam to support my explanation to the patient. Educate the pt that her body is still most likely in a hypersensitive state following her two MVA’s. I would also reassure the pt on prognosis and POC of how we are going to get her better and reach her goals.
5. How do you expect to progress your treatment program over subsequent visits?
• I would focus on pain modulation early due to her self reported pain levels educating her on the importance gentle continued movements in the her painful ranges. Manual therapy STM and mobilizations to tolerance at identified lumbar and cervical regions.
• Incorporate more functional exercise as pain levels decrease such as squatting or bike for cardiovascular exercise to promote blood flow to affected regions and promote healing. -
1. What are your top three diagnoses based on the subjective information? (ranking order)
– disc referral
– paraspinal myalgia
– facet arthropathy2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
– Central nerve tension: you’ve cleared isolated cervical flexion as a generator of familiar pain, however cervical flexion as a structural differentiation to + Slump recreates shoulder blade pain; PSLR recreates LBP, and Hip ROM WNL without strong recreation of her pain (I’d be interested in what ROM somewhat recreates this).
– Paraspinal myalgia: She has (B) sxs at the shoulder blades and around L4/5. The narrative of her story fits, as these supporting mm groups may be in a more protective mode d/t 2 accidents relatively close together. This could fit with her aggs and sx quality, as flexion, returning from flexion, and lifting would require these mm groups to kick on/ stretch. It’s also noted that she has inc turgor and apparent tone with tenderness to touch.
– Facet arthropathy: Although both MVAs were at relatively slow speeds, they occurred in cardinal planes requiring facets to flex and sidebend. This pathology fits with the aggs, nature, quality, and location of her sxs. That being said CPA to TS and LS didn’t recreate her sxs.
3. What subjective and objective information do you feel is missing and would have been helpful to assess with this
patient?I’d want to know more about her hip AROM/PROM to differentiate its involvement from LS. I’d want to know more about her scapular stabilizers and PQRS, since she reports that movement is harmful to her. I think a resisted trunk extension test would be a good tool to differentiate a myalgia impairment from a facet or disc impairment.
4. How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this
patient regarding prognosis?I think being in 2 car accidents close together feels like a yellow flag, since she’s probably more frustrated and is likely to feel like she deserves good care. That being said, she was a trooper and simply walked to the ED after the MVA.
She seems really cautious with her movement, so I’d keep it simple and draw a relationship between her current status and her ability to heal appropriately after the first MVA.
5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie
regarding patient education, manual therapy techniques, therapeutic exercises, etc.I’d try to build her sense of self-efficacy quickly by giving her meaningful, functional tasks that she can accomplish pain-free. I’d keep it as active as possible, with concurrent respect to the needs of her pathology and potential pt value of needing to feel cared for. HEP could be movement-based, rather than exercises.
Love it Casey!
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1. What are your top three diagnoses based on the subjective information? (ranking order)
– Dural irritability in TL region
– Disc referral
– Myofascial strain of musculature in TL region2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
– Dural irritability: bending over increases pain, slumped posture increases pain, braced posture with functional movements, MOI
– I believe that her dural irritability has led to concurrent myofascial symptoms3. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient?
– Interested to know which movement recreated shoulder blade pain with Slump
– H&I testing and lumbar quadrant testing
– Resisted lumbar/thoracic movements
– Myotomal screen4. How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this
patient regarding prognosis?
– I would discuss how after the initial injury, the nervous system got irritated and tensed up. Now that it is tensed, it doesn’t want to move, as movement is now going to be perceived as painful. This likely has impacted the muscles, since the nervous system didn’t want to move, now the muscles are also tensed and irritable as well. I would give advice that it is important to get the muscles and nerves moving again, and that your job is to assist this movement in minimally-painful ways (finding positions of comfort). I would also re-assure patient that nothing is permanently injured, and that it is safe to move and will not cause further injury, even if there is pain.
– I believe this patient will have a good prognosis based off the info given. She chose PT rather than a completely passive treatment. She is motivated to return to doing more at work and playing with her daughter (also important that she is still working). She is probably just fearful of movement at this point.5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie regarding patient education, manual therapy techniques, therapeutic exercises, etc.
– If STM is not too painful, I may begin there to get her musculature to relax. Then I would find positions of comfort, likely working into lumbar extension with prone press-ups or something to that effect. I do Slump nerve flossing (whichever actions do not reproduce any pain). If not too irritable, I would do open-books with short lever arm to the L, as the R seems to be more irritable.
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