June Journal Club

[Katie Long]

Subjective: Patient is a 48-year old male presenting with right sided neck pain starting about 1.5 weeks ago that “felt like a pinched nerve”. He could not find any relief until he saw his MD 5 days prior to PT eval, who gave him an oral steroid dose pack. Since then, his pain has improved and now reports worst pain of 3/10, current pain 1/10, but reports that he is afraid his pain is going to come back after the steroid pack runs out. He stated several times that his neck “feels like it needs to pop or crack and it will feel better”. He reports his pain as a medial scapular border ache that extends into the upper trap and posterior arm, which stops at the elbow. His neck often feels fatigued. He denies NT or sx distal to the elbow. Sx worse in AM, takes ~30 minutes and a hot shower to feel better.
PMH: Previous incident of neck pain 3-4 years ago with numbness into the 4th&5th digit, for which he received PT (“they popped and manipulated my muscles and it got better, I haven’t had trouble with it until now”). This episode is worse than before, does not feel similar.
AGGS: sitting at desk and working on computer, waking up in AM, falling asleep at night, sitting still for >1 hour
EASES: oral steroid, self-massage, hot shower, placing a towel under neck (initially made it worse, then improved)
GOALS: decrease pain, preventative care, HEP, neck stretches
NDI: 10%

Objective
Shoulder clearing: (-) for sx provocation
Cervical ROM:
– flexion: reproduction of sx (neck + scapular pain)
– R extension quadrant (neck and some scap pain)
– L flexion quadrant (MOST neck, scap, posterior arm pain)
– rotation and SB equal and asymptomatic bilaterally
Special tests:
– (+) R Spurlings for neck and scapular pain
– Compression in L front quadrant (+) reproduction of all sx
– Traction in L front quadrant (+) relieves sx
Palpation: R upper trap TTP
Muscle testing : cervical extensor endurance >55 seconds
Posture : moderate FHP
Neurodynamics : (-) ULTT bilaterally for sx provocation, able to achieve within 20 degrees of terminal elbow extension bilaterally
Joint Mobility:
-PPIVM/PAIVM: R hypomobile and tender
-CPA: hypomobile & painful C4 & C5
-UPA: L normal; R C4-6 hypomobile & painful

PICO: In a patient with acute-on-chronic mechanical neck pain is combination thoracic and cervical thrust manipulation as compared to cervical and/or thoracic mobilization superior in reducing pain and improving functional outcomes?

1.This patient believed manipulation would help him due to his previous experiences with PT. In patients with preconceived notions that they need the “crack” how do you address this bias within your interventions?
2. In regard to Eric’s post on biases earlier this week, how does your personal bias effect your treatment selection in treating a patient like this? Would you manipulate him day one? Why or why not?
3. How would you address this patient’s fear that his sx will come back once he comes off the medication?
4. What are some of your “go-to’s” with this “type” of patient? I feel like I’ve had a recent influx of “this patient”. I am interested to hear how you all treat these middle-aged patients with mechanically-driven stiff, painful, necks.

Attachments:

You must be logged in to view attached files.

[Justin Pretlow]

Hi Katie,
Thanks for posting.
I think you address the preconceived notion of needing the “crack” by educating/explaining that manual techniques, including but not limited to manipulation, will be part of his treatment plan. Explaining that manipulation may play a (small) role in his treatment should make him feel that his preferences are being listened to but also help him understand that PT is more than getting your neck cracked.
I think I have a bias that makes me think twice before providing a treatment that a patient has specifically asked for. I think it’s because I want to make sure I feel it’s the right treatment at that moment. So, I try not to let their request or preference weigh as heavily on my decision. I’m not sure this a good thing though. I guess you could argue that I risk losing some patient buy-in if I’m too rigid in my decision making.

[Tyler France]

Hey Katie,

I agree with Justin that I think the best way to address his focus on manipulation is to educate him that it will be a part of a larger treatment plan, but certainly not the only intervention. If you feel that he is appropriate for manipulation, I think that you should perform it as he seems to believe it will help. I feel that we should almost always attempt interventions that the patient thinks will help if there is no contraindication to the technique. I have some trouble addressing concerns that symptoms will return with cessation of medications in my patients. If the medication is an anti-inflammatory, I usually tell them that there are other ways to control inflammation aside from steroids if his pain does return. With this type of patient, I have progressively incorporated more SNAGs as part of the HEP to continue to address these hypomobilities.

[Eric Magrum]

Before this discussion goes to much further along this thread (to manipulate or not); I would make sure manipulation (Grade V techniques) were truly his expectations (“they popped and manipulated my muscles and it got better, I haven’t had trouble with it until now”); and his presentation is similar (non radicular this time); and indicated by a cluster of findings.

Not to derail the conversation/discussion; but here is a great library builder article with some things to think about with this case and similar patient presentations, especially when multiple directions of movement reproduce.
In my experience, this differential/thought process about the tissues is rarely on the minds of residents.

Think how it changes your treatment decision making versus add more energy into a system that is acutely inflammed inside the joint.

Food for thought – good article to review.

Keep up the discussion

Attachments:

You must be logged in to view attached files.

[Jennifer Boyle]

Hey Katie! Thanks for posting. I feel that in response to your question about his fear of coming off medication you will have to have conversations on how PT and exercise can be its own natural “medicine”. With this I would dip further into pain theory and how finding some sort of physical outlet and exercise prescription in junction with PT techniques can help him manage his sx without the need to depend on drugs.

I was also wondering what you meant by saying this “type” of patient.

In response to the prior discussion to manipulate or not- I would probably be hesitant to do this day one and I would use mobilization techniques. As stated above by tyler I would be nervous to lose some bye in but I feel like the evidence Eric posted would be a great conversation to utilize with the patient describing the same effects can be reached with a less aggressive technique.

[Katie Long]

Hey Jen, what I meant by this “type” of patient was a patient with history of previous neck pain who now presents with neck pain following a somewhat benign “trauma”. Painful facet opening and closing of apparent mechanical nature. Fear of neck pain returning. No apparent neuro involvement. etc. I feel like I have a handful of these similar patients right now and felt that this journal club would be a good way to get the most bang for my buck in addressing this patient population I seem to be seeing a lot of in the past month.

I like your idea of utilizing the “exercise as medicine” analogy. Luckily, he is already pretty bought in to therapy because of his previous successes, but Ill definitely see if I can work it in.

Justin- I agree with you about the bias regarding patient requests. I often feel the same way and am maybe less inclined to incorporate the intervention (often they want “massage”) unless it really is necessary.

Tyler- I haven’t incorporated SNAGs yet! Ill try that this week.

[Katie Long]

Eric- Thanks for the library builder. It was an interesting read. I don’t think that I had ever considered that the composition (and potentially the innervation) of these meniscoids would change with age, although that makes sense. It definitely makes me think about the utilization of some traction and mobilization over manipulation to the locally inflamed/symptomatic joint segment to potentially decrease irritability as compared to potentially increasing irritability.

[Sarah Bosserman]

I think you mentioning that “This episode is worse than before, does not feel similar” would lead me to be sure that I though manipulation is appropriate this time around, relying on my clusters of symptoms/CPRs to help my potential bias (and his) towards picking a treatment based on someone else’s treatment. Sounds like he has already bought into the PT process, so I don’t think you are likely to loose too much by not manipulating the first day. I think education is key, giving him self treatments that are successful (whether its SNAGSs, stretches, etc) so he feels like he has control of his symptoms and may be less fearful when he finishes his medication.

[Justin Pretlow]

Thanks for posting this article – entrapment or extrapment of a meniscoid is not usually on my mind when trying to determine the source of a patient’s cervical pain. Given that Katie’s patient responded well to distraction, then manual traction as a component of treatment makes sense. Considering that multiple directions/planes of movement provoked symptoms, I can see opting for mobilization over manipulation.
One of the patient’s goals was to learn some stretches to help the neck. With a patient like this, with multiple flexion and extension biased provocation of symptoms, I find it difficult to decide what type of neck stretches may be beneficial. I probably wouldn’t assign stretching for HEP initially. Does anyone else have difficulty with this?

[Justin Pretlow]

After finishing Katie’s article, my oversimplified take away from the author’s conclusions is: Outcomes are no different if you pragmatically utilize thrust or non-thrust manipulations in this patient population. Did anyone come away with a different message?

[Tyler France]

After reading up a little more on the meniscoid, I would likely opt for cervical mobilization with this patient when you take into account the acuity of the condition and the fact that he is having pain with facet opening and closing. You can always consider thoracic manipulation to decrease some pain in the cervical spine if your patient ends up expressing the desire to be manipulated. That may be enough to satisfy patient while minimizing the amount of energy that you put through the cervical spine.

Justin, I had the same takeaway from Katie’s article, that it seems like a pragmatic approach is better than a prescriptive approach when it comes to outcomes (duh).

[Laura Thornton]

Hey Katie –

You’ve got some great information from the evaluation to start treatment.

I would add a few things:

– There is a tendency to group all neurodynamic testing into the median-biased test for the “catch-all”, however when you have such a specific route of pain along the posterior arm, I would test ulnar-specific ULTT to really rule out the neurodynamic component (especially if the posterior arm pain is reproduced with cervical flexion quadrant AWAY from the side of pain).

– The fact that you were able to reproduce his pain with compression, then immediately resolve it with distraction, is a powerful buy-in and educational tool. From this, I would go into teaching him self-distraction techniques for home to perform when he’s sitting throughout the day, rather than “stretches” (is flexibility really the issue?), then also use it to talk about load-sensitive tissues and positioning techniques to decrease pain. Manual traction is a great technique to perform during nerve glides, joint mobilizations, active movements, etc as he continues to improve.

– It’s interesting to think about biases with this patient because there are several reasons why you would classify this patient into a “mechanical” treatment classification (painful and hypomobile segments, pain with extension/quadrant, clear neuro), therefore go right into manipulation/mobilization, because we think mechanical = joint mob/manip. But, by doing this, you can at times bypass the most important information that you got from your eval, which for him were his load sensitivity and response to compression/distraction. Classification of clinical presentations are an important piece to the puzzle but you also don’t want to miss out on other asterisk signs that could potentially be more functionally meaningful at the start.

Sorry I have to miss journal club this month but looking forward to hearing about the discussion and continuing on the discussion board.

[Author]

Posts