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Thanks for your input Hunter – here’s something to consider.
Sometimes with a history of TMD, we can bias ourselves thinking that ALL headaches are cervicogenic headaches.
In fact, based on the International Headache Society (IHS) classification system, there are more than 100+ diagnoses that contribute to headaches and cervicogenic headaches being only ONE possible diagnosis.
I would recommend considering other diagnoses (tension-type headaches, migraines, etc) and ensuring that we do a thorough subjective history on her headaches and avoid immediately assuming this is cervicogenic in nature.
Why is this important? Management and decision making:
– Does this require referral or multi-disciplinary management?
– Is this within our scope of practice?
– What prognosis do I expect? Will this improve with management of TMD?Sounds like a great start!
Keep us posted on your reassessments and further thoughts.
Thanks for such a thoughtful reflection Emily! I have some thoughts for you.
It can be initially disconcerting when you see a body chart with bilateral paresthesia. That’s why having a thorough and complete neurological exam is so important! It sounds like you did such examination (both subjective and objective) and cauda equina syndrome is much less likely on your list.
It is possible to have bilateral radicular pain – I would next ask about the behavior of symptoms between the two legs. That can also help you determine is this a central problem (such as a central herniation causing bilateral nerve root compression) or a peripheral compression (such as at the posterior hip or ischial tuberosity) separately in each leg. Do they always get numb together at the same time? Is the location of paresthesia the same on each leg? It is always related to lumbar flexion positions?
The palpation to the sciatic nerve recreating LBP – I think that speaks to the mechanosensitivity to the nervous system. The connective tissue of the nervous system structures can especially become sensitive to both mechanical (eg compression) or chemical (eg inflammation) stimuli after injury. That can affect both the peripheral and central parts of the nervous system, and it can also affect the environment around the neural structures or where they innervate (which may relate to the trigger points you found).
Would she be a candidate for incorporation of a McKenzie progression or at least have that as a starting foundation for her plan of care?
I also thought the article section “the Role of the PT in the Screening and Detection of SI-SM Myopathy” was really informative. Made some good points about proximal vs. distal muscle weakness, use of dynamometers instead of MMT, and paying attention to the timing of onset of symptoms.
Sarah you mentioned a few ideas like the endurance testing and questioning on the location and behavior of soreness/fatigue.
Good article to keep in your libraries!
Sarah, thanks for sharing your case. It should be an interesting JC!
Would you mind sharing more details about your objective evaluation? ie joint mobility, special testing, palpation, cervical screen, etc.
Nice initial discussion guys!
Interesting and important points about the relationship between her jaw pain and headaches. I also appreciate the point about the chewing from side to side – great idea to determine joint compressive load sensitivity!
So we’ve honed in on our differential list so far:
Myogenic pain
Arthrogenic pain
Cervicogenic painLet’s dive deeper into subjective history – what else would you want to know that may help to differentiate between myogenic vs. arthrogenic pain referral?
Thanks for sharing Sarah. We do see a lot of inconsistency between protocols for a number of factors and individuality plays a significant role in development of a plan of care.
But on the flip side, the consistencies between protocols may be more important. Protocols do provide clinicians with a guideline on what to protect and how to protect. They may not be as important for what to do, but what not to do.
Can you or David find an example of this in the study Kyle listed?
Hey Steven –
This is an interesting thought and made me do a little digging into the literature.
I wonder if there’s a deeper concept here. Have you introduced the techniques to the patients or spoke to them about this intervention choice? What were their responses if so?
Check this study out by Donaldson et al and especially, take a look at their thoughts on “irritability”. Let me know what you think –
Do patient expectations and perceived benefit have any role in hesitancy from them or even from you?
Thanks for your post Erik – it’s great that you’re posing questions and not taking things at face value. I’ll counterpoint – if the patient who you speak of was satisfied with only getting thrust manipulations for their care, why would they be in our clinic? Are there other components to the patient’s problem (weakness, guarding, decreased mobility) that are the underlying mechanisms for their pain? Are you ever using passive treatments alone in your POC?
HVLA thrust manipulations are valuable, powerful tools that we can use to supplement WITH active, exercise approaches to address patient’s problems. It’s important that we communicate to patients on the rationale behind these techniques, to ultimately help them move better. We, as clinicians, need to know the emerging data to understand the true effect of these techniques to then use them ethically and intentionally in our practice.
With this reasoning, we also have to be judicious about who we decide to perform these techniques on. If you believe that it will do more harm than good, then move in another direction to address the patient’s problems. I think it boils down to two things: what does the patient value in their care and what do you, as a clinician, think they would benefit from to achieve the ultimate goal >> exercise, activity, movement.
On another note, don’t forget about treatment effect sizes in intervention studies if the authors don’t report. Easy calculation that can give you the magnitude of the difference between the groups.