[nhoover17]

So general consensus so far is that I should have included more of a cervical component and from what I have researched during her care, I would agree.

I have implemented the MWM techniques in clinic with some success, although she is not really in pain during our visits so that has been hard to gauge success other than subjective report of decreased episodes of pain after prolonged hands on handlebars time. I gave her the MWM w/ a belt for self-mobs at home and she didnt like it/didnt find it an effective use of her time so we discontinued that for her HEP.

The initial wrist taping was so effective during her work day activities that she actually commented “I wish there was a way to tape my elbow like we did my wrist”, which led to researching elbow taping techniques.

Another question for you guys:
In these kinds of chronic pain pt’s, How are you structuring your goals and outcomes? Some of the literature (the Vicenzino article included) suggests that these pt’s may take up to a year to get better. Obviously not efficient for us to see them twice a week for a whole year.
What should be the goal for success and d/c without the patient thinking we’re abandoning them or running out of reimbursable visits?

[nhoover17]

1. this is her dominant arm, and she did not report previous hx of LE.
2. No change in current riding time or work hours
3. I have yet to be able to reproduce her tingling and per her report it doesnt happen often or with any consistency based on activity, but I agree, I should have done a neuro screen at the beginning of care.
4. no pain with palpation of the lunate or AP/PA glides of lunate. She reported her familiar wrist pain with triquetrum glides on her first visit but none since then.
6. I can add in PPIVMs and PAIVMs but I avoided manips secondary to hx of cancer.
7. Yea, the hardest part is that she has relatively low severity and irritability and she doesn’t let it get in the way of her work. We’ve talked about using bracing, splinting, and/or taping to decrease the stress of repetitive motions while working.
8. Over the last 2-3 sessions with her, I have added in some shoulder/scap motor control training and some graded UE CKC exercises to address proximal stability and see if that has an effect on elbow/wrist symptoms.
9. I have done some education on this kind of thing taking a while to heal as it didnt get this way over night, in an effort to decrease any frustration or impatience. She has been very receptive and willing to try things. she is now self-applying her wrist tape as needed.
10. After some unsuccessful literature searches, I did resort to the goog and found a similar technique to the video you sent. She has 0/10 wrist pain when taped.

[nhoover17]

I agree that I would have screened out UE involvement even with a subjective report of no shoulder/UE limitations. I most likely would not have performed neurodynamic testing on the initial visit due to the (-) findings in your Csp testing. I am curious as well, about soft tissue involvement due to R sided symptoms w/ L SB and rot but I would be more inclined to consider a facet opening restriction first and assess soft tissue if improvements were not being made.

As far as SINSS model, I think the testing was of appropriate vigor. I think you definitely want to find symptom provocation but in ways that do not skew your further testing. I do have one question for you regarding quadrant testing, do you always include quadrants even after (+) symptom provocation in cardinal planes? I have found that some cervical pts have (+) quadrants due to irritability that might not fit the rest of the clinical presentation and I think that clouds my clinical reasoning process some, how do you tease out the things that don’t fit without just ignoring them?

I think having a few comparable signs helps to streamline the follow up visits and somewhat simplifies and aligns tx goals w/ pt outcome goals, which improves pt buy in when they can see clear improvements. Aaron also preaches using therex that complements your tx and I find it makes therex choices and decisions easier when you have comparable signs as guidelines.

In our technology based world constantly staring at screens and often with shoddy posture, I think most pts will benefit from DNF training, and Tsp mobility, especially those w/ symptomatic Csp dysfunctions. As long as there are no contraindications to manips, I try to use those often, if nothing else, just to practice my feel for different spines and different hand placements. I haven’t used Csp manips as much as Tsp, mostly because of my personal comfort level, but also because of the evidence (I can’t remember the article at the moment) showing that Csp manips are relatively similar to mobs in decreasing pain and improving ROM.

As far as my progression is concerned, I try to use isolated DNF training first in sitting/supine/prone depending on pt comfort level and ability to engage the correct positions and then progress to scapulothoracic stability while maintaining proper DNF activation. It has been very interesting to get other perspectives on this, especially with the use of lasers. I have not been exposed to that in my prior clinical rotations but I can think of a handful of current pts that may benefit from using it.

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