[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.

[helenrshep]

This course was tough for me! Like Lauren, I didn’t really have a good spiel or ready made examples to use when talking with patients about their pain. A lot of times I was too concerned to broach the topic, thinking patients would hear “it’s all in your head” so I stuck with the anatomy education and discussion of biomechanics. I think my patients have really been missing out. I really wanted to come out of this with a “spiel” but realized that it’s not a one size fits all type of thing. I think really understanding the current literature on pain will allow us to adapt our discussion to be specific to each patient. Yes we might use a metaphor as part of that, but not the only part.

Other take aways:
– I like the buffer – it seems encouraging that your body has this buffer system where you can’t (usually) cause more injury because you get the “stop” signs way before tissue damage.
– I like the “your body is an unstoppable healing machine” statement. I think a lot of our patients don’t know that.
– I like the idea of talking about this stuff gradually, like while doing manual stuff, and not just sitting them down for 30 minutes to educate them.

I need to keep reading my notes and digesting…

[helenrshep]

Apologies for the double post but I had more thoughts! – I also question the functionality of isometrics. You can do all the plantarflexion isometrics you want, but at the end of the day if you’re still walking then isn’t that technically an isotonic exercise in itself? And how much of a role does motor control play? Do you guys treat with isometrics or isotonics or both?

[helenrshep]

This always seems to be a point of disagreement among clinicians! I feel it has a lot to do with the patient’s irritability. I think the highly irritable patient responds better to isometrics, but I also think that has a lot to do with their perception – not asking them to go through a full range of motion “seems” tamer to them in my experience, and is consistent with the article’s point about fear of exercise. But a less irritable patient, or one that is familiar with exercise (like an athlete) may be just fine doing isotonics. Or maybe do both? I don’t think it necessarily has to be an either/or…

[helenrshep]

I really like this article for a variety of reasons. On one hand it’s comforting to know that even if we don’t have the most accurate manual therapy skills, the best exercise prescription, or the latest and greatest tools, we are still going to help our patients. It’s a little bit of the pat on the back, “it’s going to be okay” to clinicians – if we’re really trying and want to help our patients get better, we’re at least accomplishing something with just that. If we are confident in what we know, are kind and engaging with patients, and have a positive attitude then we will likely still have good outcomes. I agree with Taylor that the placebo effect is an area of low hanging fruit that we can be using as part of our best practices. I also like that the article talks about how much we convey with our non verbals – the way we dress, how organized we are, what the clinic looks like, and even the paperwork and waiting room. I definitely think the entire concept of verbal and non verbal placebo effects are an area of untapped potential.

[helenrshep]

I was thinking about “fake it till you make it” too! I think we often know more than we give ourselves credit for, and being confident in that and showing positivity to our patients can go a long way.

[helenrshep]

After reading this article, I’m really excited, and a little scared, to get started using the clinical reasoning form. So often I find myself fumbling around trying to decide the best interventions and basing it on past patient patterns instead of searching the literature. This leads to occasionally over or under aggressive treatment and patients not getting better nearly as fast as they could be. I’m excited to streamline the process to start being better equipped to answer questions of “where do I go from here” and “what should I do first.”

The main thought I had while reading this article is “how do you train someone to think” – which is what all of us, I think, want to get out of this residency program. Be better – better thinkers, better clinicians. The clinical reasoning process is subconscious in many ways, as the article pointed out, however, the key is to bring it to the conscious level so it can be discussed. “Reasoning must be exercised consciously to facilitate self-reflection, change professional behaviors and thought processes, and improve diagnostic accuracy.” I think it’s important to be able to articulate your thought process with patient care and that there’s a direct translation into patient education. If you can explain (to yourself and the patient) why you’re doing what you’re doing, the patient will trust you and outcomes will be better.

I really love the emphasis on the subjective exam. I honestly thought I was taking too much time on the subjective part of my evaluations, but I think it’s important to let your patient’s responses tailor your objective exam. After all, they know their body the best, so we can be more specific with our exam and treatment if we listen to them first. I think there’s an art to gathering a subjective exam, but it is also very patient dependent – some want to tell you their entire life story and your job is to guide them and pick out the important pieces of information, and for others it’s like pulling teeth to get them to tell you anything. It will be interesting to assess the effect that the patient’s personality has on the ease of use of the clinical reasoning form. I also like the attention to irritability of symptoms – I often think I need to assess everything fully, but, as the article discussed, if the symptoms are highly irritable, we may need to back off on our exam. I also like that the article mentions going to the research after the first visit and then continuing the assessment during the next visit. I think this helps calm our desire to get it all done during the initial evaluation, and makes the obvious point that clinical reasoning is a continuous process.

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