[Taylor Blattenberger]

Working hypothesis and differential diagnosis:
a.) What is your working hypothesis regarding this patient?
Cervical disc pathology and Labrum tear
b.) What are your next 2-3 differentials? (Ranking order)
Cervical facet artrhopathy
Subacromial impingement syndrome
Thoracic facet arthropathy
Special testing:
a.) What are your thoughts regarding the special testing chosen for this patient?
Good cervical screening and shoulder testing. Impingement was on my differential so I like that line of testing.
b.) Do you feel the treating therapist should have performed any additional tests? If so, what? If not, why?
Cervical – Complete the cluster with distraction
Shoulder – Other labrum tests: Crank, grind, biceps load
Clinical Pattern:
a.) Does this patient’s presentation fit a clinical pattern?
No clear pattern here. The neck seems to be driving most present symptoms, but not in one direction that you can truly differentiate disc from facet.
b.) Briefly, what are your thoughts regarding his headache?
Interesting that mid cervical quadrants reproduced the headache. Would have liked to see a CFRT to check upper c/s involvement
Evolution of Patient’s Symptoms:
a.) What are your thoughts regarding the patient’s symptoms starting insidiously, progressing over time, and finally being augmented by a MOI.
The insidious onset with UE movements exacerbating makes me think this case has a strong cervical component.
b.) Are there any red flags?
None
Treatment
What Manual therapy and HEP would you give the patient on the first day?
MT: L foraminal opening via R SB PPIVM/PAIVM
TherEx: either SA or lower trap activation to simulate scap assist test (test one, if it works give it, if it doesn’t, try the other.

[Taylor Blattenberger]

If you guys are interested in something very research based I’ll suggest PT Inquest. It’s run by 2 Members of the American Academy of Sports Physical Therapy (formerly the APTA sports section). I find their stuff to be good clinically, but most helpful when evaluating research. They talk a lot about evaluating methodology and statistics. Fair warning, the first 15 minutes of each episode is a Q&A and some general nonsense which can be entertaining or not depending on your sense of humor. Anyway, a really good listen for when journal club and lit reviews are looming.

[Taylor Blattenberger]

I really enjoyed reading this case problem. It showed how systematic we can be to come to a very reasonable conclusion. Very sound reasoning to rule in and out hypotheses. This will definitely help my approach to similar issues. Seeing all the results play out puts what we’re doing into perspective.

One thing I found interesting from this case was the nature of pronator teres syndrome and how it typically presents with negative findings on NCV tests. To me this really speaks to the nature of the pathology. Perhaps the absence of these findings in known cases points to this being more of an exertional entramptment as opposed to being associated with nerve damage that can be identified with these tests.

[Taylor Blattenberger]

Yikes! I don’t think I’ve looked at a single TMJ case since school. Great share on the article. That really helped review the anatomy and concepts around the joint/pathology.

Leaning on the article(s) you shared, I’m going to utilize the RDC/TMD. From the subjective and some of the objective info it seems she fits in the myogenic category at least, and we can rule out cervical involvement. Did you test any joint compression or glides? We know the radiograph found abnormalities, but I am curious if the joint is driving any of the symptoms especially given the audible mechanical symptoms.

[Taylor Blattenberger]

1. What are your top three diagnoses based on the subjective information? (ranking order)
1- Cervicogenic headache – upper cervical origin
2- Cervical myofascial – Upper trap strain
3- Lower cervical facet arthropathy

2. Using your number one differential, what would you expect to be (+) during the objective exam to support your hypothesis?
-Upper cervical APR (chin tuck/poke) (+) for head pain
-CFRT (+) for ROM loss, possible pain provocation
-Upper cervical accessory motion loss, and pain provocation

3. What is your top diagnosis based on the objective information and why (asterisk
signs/symptoms)?
-Multi level facet arthropathy involving the upper and lower cervical spine.
-ROM loss, pain and stiffness with accessory movements, no radiating symptoms
-Two separate issues because no single movement provoked both symptoms.
-Upper – CFRT, C1-2 PA’s provoked symptoms
-Lower – Painful and stiff lower cervical PAMs, reproduction of lower pain with these tests

4. What Manual therapy and HEP would you give the patient on the first day?
-MT – C/S CPA C5-7 GrII-III (Low irritability so no reason to avoid the specific area, and other segments were also painful so irritability would not likely change.
-HEP – Chin tucks – limited endurance, + isometrics for analgesia

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 didn’t find anything concerning in the red flag questioning or PMH. Given the “MOI” and some of the aggs and eases I would have liked to see how resisted testing of the neck felt to assess for myofascial involvement.

[Taylor Blattenberger]

Very true. Some people already have a view of pain that will not hinder their recovery. Some people are actually in the acute or acute on chronic phase of pain that may lend itself less to overactive neurotags and overblown buffers. These patients don’t need “the talk.” What these patients need is for us to not perpetuate harmful narratives and to employ soft language. Does that patient really need the visual of their RC getting pinched under their acromion? Or can we explain this symptom in a less threatening way?

[Taylor Blattenberger]

Great points Anna. I love your point about dissonance. A lot of the things we do are being called into question, and thats a good thing. We aren’t alone, as other providers are also being challenged as information (good and bad) becomes more available. That’s why it’s so important for us to get comfortable with the uncertainty and be good consumers of information so we can provide the best care for our patients.

One of my favorite sayings: We will rarely be RIGHT, let’s just try to be a bit less wrong each day.

[Taylor Blattenberger]

One thing I will take from this course was the idea of using imaging as a green light as opposed to the absence of a red light. I think it is definitely more skilled than it sounds because in the past when I downplay imaging patients can perseverate further as if I missed something. Probably more important to bolster this with WHY its not a big deal (base rates, healing, etc.).

[Taylor Blattenberger]

I think everyone has made good points! I think one thing this article really misses is the clinical decision process. Maybe some people allocated in the isotonic group were more irritable and would have responded better to higher resistance isometrically than low load isotonics. No way to know this for sure, but definitely a difference between research application and clinical application.

[Taylor Blattenberger]

This was a really good read. I think we are really evolving our understanding of how to apply the science of pain to the patients that walk through our door. This study touches on many ideas I think are important to the application:

-Providing accurate information about pain
-Minimizing the nocebo of the biomedical explanations we have
-Practicing what we preach in clinic by grading exposure to provocative positions and encouraging less fear of movement

Helen – You’re right: it can be very difficult to covet some of these messages without coming off as dismissive or making the patient feel attacked. It’s also hard to balance movement training and education with soft language and a solid explanation of symptoms.

I typically try to paint the picture through the lens of “sensitivity.” An analogy I’ve been using more in practice has been that of a sunburn. “When you’re sunburnt, warm water can be painful over that area, but you aren’t actually doing any damage to the skin. This is similar to movement in that the muscles/joints/back is sensitive and those forces
are uncomfortable right now.” If you can frame it as something they already understand, they can be more accepting to the education.

[Taylor Blattenberger]

Hey, guys! My name is Taylor Blattenberger and I am a VOMPTI resident currently working at Shenandoah Memorial Hospital in Woodstock, VA. I graduated from Shenandoah University in 2018 and spent my first year out of school working in a private OP ortho clinic. Like many of you have already mentioned, I am looking forward to improving my clinical reasoning and critical thinking in my practice. I am also looking forward to working with and learning from all of you! See you all soon!

[Taylor Blattenberger]

This realm of literature and clinical practice has been dominating my desktop for the past 2 years. I feel there is so much to the patient-therapist interaction that we can affect and I’ve been fumbling with strategies to enhance these things most effectively.

I think this article points out a lot of low hanging fruit that we can all incorporate into our practice regardless of the patient in front of us: being engaged in the interaction, problem framing, an overall positive attitude. These things are universal and can be part of every interaction.

This article does end on a note that I feel is a bit more nuanced than the above factors. The author mentions shaping patient beliefs through our interaction.

I have found that maximizing positive contextual factors in PT practice has been a challenging balancing act. We have to minimize threat and fear while still validating the patient’s experience of symptoms. We should be very careful delivering messages like “your image doesn’t tell us the whole picture,” or “We can try and manage these symptoms without resorting to surgery,” because sometimes these things, while potentially true, can come off as dismissive and really hurt our interactions.

In this thought I reflect on an article I read earlier this year (see below, it’s only about 3 pages too. For the “TLDR” just start on page 3). I believe that validating a patient’s experience and meeting them where they are can have a great effect on the patient’s perception of the individual, and PT as a whole. These “soft skills” really are the things that drive our clinical practice every day.

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[Taylor Blattenberger]

This article absolutely reinforced the importance of a guide, such as a clinical reasoning form, in early clinical practice. In my first year of practice I had difficulties organizing my clinical exam. When I would reflect on my interactions during documentation I would find things that I had glossed over that I realized I should have examined further. That is one thing that the SCRIPT and VOMPTI’s clinical reasoning tool seeks to minimize.

This type of tool reminds me of a pilot’s checklist. Things that are understood, practiced, and routine, but very necessary to ensuring quality and safety. Each patient experience will bring new and unique challenges, but if we can learn to systematically evaluate and educate we can eliminate much of the common error in our practice.

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