[Laura Thornton]

The way I try to make sense of how happened to this patient is by referring back to the Cascade of Spinal Degeneration theory. Similar to the case presentation at the course weekend, I see this patient as traveling down the cascade from most likely initial herniation and upper lumbar radiculopathy episode, into instability stage with lateral nerve entrapment, and now possibly one level stenosis category. The addition of the inguinal hernia has added extraneural restriction to an already compromised nerve root. So, I would think that treating both upper lumbar and increase mobility along the nerve route would be treatment options for him.

Further details I would like to know: specific age (60-70?). Did he have any previous, more mild back pain before the first episode?

I would probably want to contact his physician to inform him of the findings and the hypothesis of peripheral entrapment. Since his neurological findings have gotten worse since he has seen the physician (hip flexor weakness? numbness?), I would at least want to communicate this to him/her so they are aware of the changes especially since he had a medical procedure in that region.

[Laura Thornton]

Hard to believe, but we had a male with signs and symptoms at Progress yesterday that we concluded to be Meralgia Paresthetica.

Asterisks:
– numbness in exact distribution as LCNT on L lateral thigh
– sharp pain in L lateral thigh that were reproduced with L extension quadrant (which we previously thought lumbar spine related, but could be placing tension on LCNT as well)
– previous history of inguinal hernia and repair with mesh placement bilaterally***
– upper lumbar hypomobility and pain
– VERY tender iliopsoas tendons B (L>R) to palpation
– positive for symptom reproduction femoral nerve tension test on L with cervical flexion
– positive sidelying pelvic compression that eased symptoms
– one of the biggest things we changed is his sleep positioning, he tended to lie on his R side with his head and trunk flexed (increased dural tension from above) so we had him position with his head and spine in a neutral position

Thanks for posting about this topic, definitely helped us with treatment and plan of care.

[Laura Thornton]

Thanks again to everyone for your contributions.

I have not performed any UMN tests at this point. When I said neurological exam was negative, that was a general myotome, dermatome, and DTR’s were all normal. When the sustained cervical extension brought on the new numbness symptoms, they immediately dissipated upon neutral spine but I think at that time I didn’t want to test quadrants due to such a significant new finding that I didn’t want to irritate with further testing. Now, I agree that I would like to differentiate central vs. peripheral cervical involvement by testing quadrants and I feel comfortable due to the symptoms dissipating immediately. I will re-test central cervical extension, then quadrants in neutral spine. I think the myelopathy cluster in the compromised position is a great, innovative idea that I should include in my next session but also be wary of symptom behavior and modify as necessary.

I believe that there is a correlation between posture and ribcage movement restrictions and breathing difficulty. All pulmonary testing is negative and BP meds are being currently monitored by his physician, has follow-up appointment next week to assess whether change in BP medication is helping. Despite this, I definitely have my radar up on any red flag findings and am still trying to figure out why this just started one month ago, where all the other symptoms did not have any change around this date.

Carpal tunnel testing is all negative and ULNT reproduced the “numbness” in first four fingers.

In terms of scapula/head positioning while driving, his hand is around 11 o’clock with palm against steering wheel and wrist extended. With typing, he is at a monitor and separate keyboard. Could be either increased external pressure on the carpal tunnel site, or scapular protraction, thoracic kyphosis, forward head that we find so common in these positions. I’ll need to take a look at this more specifically.

I find the methodology of this article to be the most significant factor when questioning the results and application of findings into clinical practice. I agree, the pre-tension positioning of the UE during STM intervention vs. US is a huge player and would definitely affect stress-strain properties of the nerve especially for a long treatment duration. The ultrasound parameters are non-thermal at .50 w/cm2, and there is no stated reasoning for why this would be an appropriate comparative intervention other than a “non-movement based intervention” like previous studies before.

[Laura Thornton]

Wow, thanks guys. These responses are fantastic. You are all awesome.

T4 syndrome is a foreign diagnosis to me, first time I have heard of this. I did a little research and it’s a really interesting presentation with bilateral numbness, paresthesias, DIFFICULTY BREATHING, pain more at the end of the day, amongst other things. Few case studies, but not much literature about it. I’m going to keep my eye on it, if anyone has any more information on this please let me know.

Today was the second follow up and the first day I did L thoracic UPA mobilizations and I did them in R sidelying (just as Oksana recommended). In this position, I could do a lot of soft tissue work around his R scapula as well as scapulothoracic mobilizations and get underneath to serratus. I’m going to try the thoracic mobilization technique Sean mentioned in sitting with arms crossed, that’s a great idea.

I have not tested cervical quadrants with him, I need to next visit. I think that will really help with getting the extent of cervical involvement, I’ll update everyone when I do. Spurlings and distraction negative without going into quadrants, I’ll add this in next session. The sustained cervical extension was passive.

I performed Adson’s test during the initial evaluation for TOS and the test was negative, strong pulse. Just like Sean said, the tests for TOS don’t have great metrics and there’s so much going on with him, I kind of put them to the side.

Nick – yes! I agree I’d love to start doing more active thoracic mobility exercises with him. Added in some simple thoracic extensions over ball, will add some more in at next session. Thanks for the recommendations.

Big update from today’s session – patient reported that after last session he also noted that he gets the “numbness” (not original burning, but the symptom from sustained cervical extension) when typing on his computer and when driving his car and his palm is against the steering wheel. SO, this has got me thinking do we have a carpal tunnel involvement? Double crush?

It’s cases like these that make me excited to come into work every day. So interesting!

[Laura Thornton]

In terms of thrust manipulations in patients with osteopenia, one of the consistent factors I have looked at is how recent their bone scan was. I would feel more comfortable if it was more recent than say, 5 years ago. The specific osteopenia score is an important distinction as well and something I need to ask in more detail (and if they don’t know their osteopenia score, I think it’d be worth finding out before considering further).

Glad you mentioned the legal action, that’s something that would make me pause as well especially with an aggressive pursuit as his is. I’d like to look into this further.

Thanks for posting those articles. Looks like this has been investigated a number of times over the years, but conflicting results just like you said.

[Laura Thornton]

Great job today Nick. I’d like to share some feedback from the presentation to provide some post-hoc discussion. I want to also apologize to you for misunderstanding the forum we were to have before the Journal Club today.

You picked a really interesting article and topic. It was a nice change of pace to look outside of just the contents of the article and into personal biases and potential lack of equipoise in certain RCT’s.

Despite the potential problems that arise with this study, it encourages me to increase my confidence in adding cervical manipulation into my toolbox to use when appropriate.

I will be curious to see if you are considering either thrust manipulation with your current patient. There was a lack of segmental assessment in the current study and yet significant results with pain relief. This weekend, there was still some uncertainty of what is causing his pain (spinous process encroachment, facet joint, segmental instability). Is this treatment on your radar for him?

[Laura Thornton]

In response to Nick’s discussion questions, here’s an interesting article I found and will refer to during Journal Club this afternoon. Focusing more on clinical and personal equipoise with RCT’s in manual therapy interventions and treatment groups.

[Laura Thornton]

Interesting topic. Like Nick, this hasn’t been on my radar but I’m glad I can add to my differential diagnosis list. The Pelvic Compression Test is a pretty creative idea by placing the inguinal ligament on slack and therefore decreasing tension on the LCNT.

I would be curious to see if adding cervical flexion/extension to the neurodynamic test described in the article would further change the symptom response even though we’re looking at entrapment distally. If so, thoracic mobility intervention?

The article states multiple anatomical variations involve close proximity of the LCNT to the origin of the sartorius muscle. I wonder if performing the Thomas Test would be valuable for symptom provocation by placing LCNT on tension while evaluating iliopsoas, rectus femoris, and sartorius flexibility. You could also add medial rotation of the femur to place more tension on sartorius.

[Laura Thornton]

Great article Nick. I think Sean’s example of the close relationship between shoulder and cervical/thoracic spine perfectly describes how important a thorough shoulder screening is for cervical spine, and vice versa. I agree with Alex, it would have been beneficial to know more information on the source of the pain symptoms of the patients instead of just chronic, non-specific neck pain.

To respond to some of your questions:
1. To emphasize lower cervical extension without upper cervical extension, I would prescribe movements that start from the upper-mid thoracic spine and have the upper cervical spine blocked or with active cervical retraction. For example, performing active thoracic extension exercises with prone over ball or prone over bench (hands behind neck with interlaced fingers to block cervical extension) or while supine on foam roll with head supported, performing theraband UE exercises to strengthen lower trap/rhomboid/lats.

What do you guys think of using prone cervical retraction as a relative lower cervical extension/upper cervical flexion movement? It’s certainly not getting as much extension range as the movement in the study, but might be enough in the beginning for gravity-resisted strengthening.

3. Some general subjective points that I would add would be any history of concussion/MVA, long history of working a desk job or sustained positions (thinking postural syndrome, upper crossed syndrome, etc), or complaint of worsening neck pain at the end of the day.

Just some general thoughts about the article:
– It’s hard to relate videotaping to an actual clinical evaluation, especially with only one viewing angle and no sound. There is weak applicability of this assessment method from one static position and from 2 meters away. How much do we spend this far away from patients in real life scenarios, without sound, without knowing response/provocation of symptoms, and without palpation?
– Practice for two of the tests were not allowed before taping due to developers advocating “spontaneous performance” for these tests. As AJ spoke about today, we want to watch this “spontaneous performance” of all active movement without feedback at our initial assessment. I’m curious to know if the results would change if all movements were spontaneously performed, instead of the 5-8 practice trials beforehand.

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