[Michael McMurray]

Hi to all. My name is carmela and have been practicing in an OPPT hospital for a while now in MD. Did my tdpt at EIM in 2016. In regards to my goals for this course series, i’m hoping to enhance on critical thinking and updates on manual techniques. Looking forward to learning from the group.

[Michael McMurray]

Hello everyone. My name is Reid Moseley. I graduated from Virginia Commonwealth University in 2018 and I have been practicing in Charlottesville, VA at Move Better Physical Therapy for about 16 months. I currently work with patients of all ages and orthopedic conditions, including post op and non post op. I’m especially interested in working with more active populations, including high school athletes, fitness athletes and runners. Over the next 6 months, I am hoping to learn new manual techniques, improve old ones and sharpen clinical reasoning skills.

[Michael McMurray]

Hey everyone, My name is Jeff Tsai. I graduated from Marymount University last year and have been working in outpatient ortho at Fair Oaks Orthopaedic Associates every since. I work with a lot of Post-op patients but will see a variety of of non-surgical ones from teens to the geriatric population. I’m hoping to improve my manual skills and clinical reasoning over the next 6 months. Look forward to meeting everyone!

[Michael McMurray]

Hi everyone! My name is Caitlyn Kost, and I am an alumni of Shenandoah University. I have been practicing for just over a year, and I work at Virginia Therapy and Fitness Center in Reston VA. As a clinic, we predominantly treat neck and low back pain, but will also see athletes, geriatric patients, teens, etc. I am looking forward to improving my extremity manual therapy techniques and clinical reasoning skills through the course!

[Michael McMurray]

Hi, everyone! My name is Moonhee Jo. I’m graduated from a PT school in my country back in 2007 ( Korea ), passed NPTE in 2009 and came to the U.S. in 2010. I finished my tDPT in 2012 from Dominican college in NY state. I currently work at my own small out patient based PT office in Woodbridge VA. I am looking forward to refresh, update and review my overall skills or evidences through this courses. I’m exited see you all soon.

[Michael McMurray]

Hey, everyone! My name is Brandon Wenger. I graduated from Marymount University in 2018 and have just finished my first year in the clinic. I currently work at Performance Physical Therapy in Chantilly, VA. The clinic I work in is an outpatient Ortho clinic, but am able to get a variety of patient cases. I really enjoy working with sports athletes and those looking to get more active. I am looking forward to this course and improving my overall skills and techniques in order to improve the quality of care I can provide. Looking forward to meeting and learning from all of you!

[Michael McMurray]

Hello, my name is Mohammad Wahdan I graduated from Marymount University in Arlington VA. I have been practicing for 3 years and am currently working at Phoenix Rehab in Vienna VA. I started off working in acute care however after about a year I decided to transition to outpatient orthopedics. I’m looking forward to this course to help further develop and improve my manual therapy skills and clinical reasoning.

[Michael McMurray]

Hey everyone, my name is Sara Walker and I am an alumni of Shenandoah’s PT program. I have now been practicing for 2 years and am currently working at Advantage Physical Therapy in Gainesville, VA. When I came out of school I took my first job in outpatient neuro but after 9 months out of of the ortho world I desperately missed the hands on care. I’m looking forward to starting this course for a refresher with the manual techniques and further develop my clinical reasoning!

[Michael McMurray]

Have a read post your thoughts on how these tools can help with your goals for residency this year.

All throughout my internships and even now during my first year in the clinic, I have always been focusing on having an efficient flow to my evaluations that allow me to gather the information necessary to better access the patient but to also focus on the patients symptoms and irritability in order not to flare up their symptoms. In school we were provided with a evaluation template that covered all the areas to cover and focused on the SINSS concept but was rather overwhelming and seemed impossible to cover in a realistic time frame during an evaluation in the clinic.

While reading and rereading this case report, I loved the fact that the SCRIPT tool was focused on all parties involved in the evaluation: the patient, the mentee, and the mentor. It is a very systematic tool, allowing for a framework to hypothesize, assess, evaluate, reevaluate, and reflect on subjective and objective findings all while focusing on the patient and their symptoms and impairments and how they conflict with their previous level of function.

Throughout this residency, I believe that this tool, SCRIPT, will provide for a structural sound foundation or framework for evaluations and follow-up visits. With this foundation, I believe that I will be able to better organize and communicate my thought process and clinical reasoning to myself and my mentor. I believe that it will also allow me to better self-reflect and learn from my mistakes or shortcomings to allow me to become a better clinician. Having the foundation written out and organized on paper, more explicit, will allow for facilitation of improved discussion between my mentor and myself and therefore a better learning experience. Overall, I believe this tool will better myself as a clinician to become more organized, better identify differential diagnoses and potential red flags, and provide a more thorough evaluation and overall improved experience for the patients.

[Michael McMurray]

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

[Michael McMurray]

For those interested in running/working with runners, Christopher Johnson is an awesome person to follow. He is a PT based out of Seattle and teaches around the country. His business site is zerenpt.com; you can also friend him on FB. He also has a group called the Runner’s Zone which does cost money annually to be a part of but it’s completely changed my practice – you get access to running gait analysis training, journal clubs, and a FB group with other practitioners where there’s a TON of information sharing going on.

Also in the running PT world, on twitter: Rich Willey and Shefali Christopher. both are making interesting contributions to the literature. Jay Dicharry is another big name in running medicine – he’s written two books on strength training for runners. Both are geared towards the general population but they’re definitely worth reading if you feel like that part of your practice needs some new ideas.

Also some other good podcasts:
-BJSM (15-20mins, summary of the literature)
-Mike Reinold
-PT Inquest (usually an hour, it’s a journal club/paper discussion in podcast form)
-Clinical Athlete Podcast (usually an hour, interview form, topics in sports medicine)

[Michael McMurray]

thestudentphysicaltherapist.com

^Has a good list of special tests with descriptions on how to perform them and how sensitive/specific they are. Also references articles that talk about the tests themselves and mentions clusters of tests here and there. Very helpful in PT school with review before tests and practicals.

-Kurt

[Michael McMurray]

1. What are your top three diagnoses based on the subjective information? (ranking order)
a) posture-driven upper cervical jt dysfunction with specific consideration given to A/A jt due to HA pattern
b) myofascial pain from SCM (ear and chin pain, HA), suboccipitals (HA), levator strain
c) TOS/brachial plexus irritation from poor posture, or other separate elbow/arm issues since pt is L-handed

2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
a) upper cervical jt dysfunction: poor posture crunching upper cervical facet jts, PPIVMs tight and PAIVMs reproduced ear pain, retraction reduces suboccipital pain
b) myofascial pain from SCM (ear and chin pain, HA), suboccipitals (HA), levator strain
c) TOS/brachial plexus irritation with distal nerve symptoms since ULTT, Spurlings, and distraction did not reproduce or alleviate concordant pain

3. Based on your diagnosis, how would you tell this patient your findings?
Use the spine model for demonstration of facet jt irritation and how retraction reduces pressure through upper c-spine, bowling ball on a popsicle stick analogy to explain strain in posterior neck musculature, emphasize posture and correlate increase in symptoms with more time seated in poor posture.

4. What HEP would you give the patient on the first day?
-possibly self-massage with 2 tennis balls in a sock to upper cervical region depending on patient’s understanding/ability
-upper cervical nods & neck retraction — probably in seated since supine is uncomfortable, or supine with more pillows to elevate head to comfortable position; emphasis on small and gentle motions so as not to irritate chronically tight and irritated tissue
-try either heat or ice at home depending on level of irritation following self-massage and ther ex — pt preference indicates heat works better for her, but with pain >4/10 would encourage her to use ice

5. Obviously I did not test everything on the first day. What other subjective questions and objective tests would be helpful to know regarding this patient case?
-scapulothoracic stability: middle/lower trap and serratus ant strength
-ant chest muscular tightness — pec major and minor?
-neuromuscular control: can she perform scap retr?
-thoracic spine mobility
-elevated 1st rib?
-scalene tightness?
-check arm for myofascial irritation of common hand/wrist flexors/extensors

[Michael McMurray]

1. Lower C/S facet dysfunction, Upper cervical facet referral, TMJ
2. Lower C/S facet dysfunction → pt’s sxs started approx. 14 years ago. At this time, we are unsure if a traumatic event happened during the time of onset which may be contributing to the psychosocial aspect of her sxs. Facet irritation can lead to under activity of muscles such as the deep cervical flexors, and cause tightness of the suboccipital muscles, upper trap, and SCM. Over time, tightness of these muscles could effect joints both proximal and distal to the initial location.
-4/4 of the C/S radic cluster appear to be negative
-Symptoms began at a young age and have not improved → indicating psychosocial involvement and chronic hyperactivity of various muscles
-Both Upper cervical and lower cervical joints are limited and reproduce pain
-Retraction reduced symptoms, indicating that posture is influencing symptoms
3. I would first address the pt’s posture, and discuss how her every day posture may be worsening her symptoms. I would provide her with positional modifications and encourage rest breaks throughout the day. I would ask further questions to determine if there was any traumatic incident that occurred around the onset of her sxs 14 years ago, as this may be influencing her sxs → If this is the case, I would incorporate pain neuroscience education on day 1, emphasizing that tissues are not damaged from and event that happened 14 years ago. I would then explain the reasoning for referral and “spreading” of sxs, and why she has pain into her anterior neck and ear region.
4. Postural education, activity/positional modification, deep cervical flexion in supine, cervical rotation in supine, scapular retraction
5. Previous traumatic event around the initial onset on sxs, why previous treatment was not successful, what types of treatment did she receive in previous PT. Does the patient have pins and needles on just the left? Has she been dropping things recently?

[Michael McMurray]

1. C8 Nerve Root/Radiculopathy, Upper Cervical Joint Dysfunction, myofascial pain

2. Upper Cervical Joint Dysfunction potentially causing cervicogenic headache. Reasoning: C2/3 PAIVM increased complaint of left ear pain, Cluster of tests for radiculopthy didn’t reproduce her CC, protraction pain (upper cervical closing joints), retraction diminishes pain (opening joints), prolonged sitting aggravates symptoms

3. I would tell my patient she’s been a student since these symptoms came on and likely spends a ton of time reading with poor posture. We were partially able to reproduce symptoms with poor cervical posture (forward head/protraction) and her symptoms were relieved with good posture/retraction. I would explain facet referral pain for the upper cervical vertebrae and how this irritation can easily cause cervicogenic headaches which is another complaint of hers. I’m not fully able to explain the C8 distribution of symptoms but she may also have lower cervical facet irritation and with a 14 year history of chronic pain I would explain the longer you’re in pain the more pain tends to refer elsewhere and cause secondary symptoms.

4. Cervical flexion strengthening, I personally also tell my patients to set an alarm on their phone as a “posture check”, self myofascial release to suboccipitals and upper traps/levator, stretching to same muscles

5. I was unsure about what the statement regarding spurlings, distraction, and ULTT being painful meant and if that means a positive finding than I would likely be leaning more towards radiculopathy but if they’re negative I’m sticking to joint. I’d like to know how often her C8 type symptoms are present and whether or not spurling created a local neck pain or more of a “pins and needles” pain as this would also be crucial information. I’d like to know her thoracic and shoulder mobility because with limited thoracic extension she may be extending more through her cervical spine causing more of a C8 compression or facet irritation throughout the cervical spine. I would ask the patient if her arm symptoms seam related to her neck pain and whether there is a pattern between the two.

Overall there’s still some uncertainty as to whether or not this is all coming from one issue or whether she potentially has multiple issues. It’s possible she has upper cervical dysfunction causing cervicogenic type headaches and corresponding myofascial impairments and at the same time has C8 irritation from lower cervical dysfunciton. I don’t want to hang my hat on one set of special tests but knowing in more detail the findings of the ULTT and spurlings would give me better insight as to whether this is more radiculopathy or joint related.

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