March Journal Club Case

[Nick Law]

Body chart: superior and lateral shoulder, scapular region, medial two digits

Outcome measure: NDI – 28%. DASH: 46%, NPRS: 3 (current), 10 (worst), 2 (best)

Subjective: 27 year old female with 2.5 months insidious onset of R posterior>anterior shoulder, scapular pain (difficult to localize), occasional numbness/pain in medial 2 fingers when symptoms are exacerbated (symptoms appear related). Pain is described as “burning, aching.” Some lower neck pain when rotating turning head (right worse than left), however neck pain not primary complaint.

As her symptoms progressed she went to orthopedic MD, X rays for shoulder and cervical spine negative (only able to view up to C7 on lateral view), referred to PT with script reading: “evaluate and treat patient with shoulder impingement, ROM and strengthening of the RTC and scapular stabilizers. Also include stretching, strengthening, modalities for cervical spine pain radiating to the right arm.”

PMH: Prior L shoulder history (reports she had some “tears” on MRI, loose ligaments however was successfully managed non operatively). Otherwise unremarkable.

Aggs: sleep (wakes up 2-3 times/night), computer work (patient has an office job in telemedicine), hand use (washing dishes, doing housework), gym exercises (UE>LE); not aggravated by any reaching movements

Eases: refraining from use of UE’s

Denies hand weakness/clumsiness

Scapular region “hot” when it gets bad; otherwise no temperature fluctuations

Primary hypothesis after subjective: TOS

Differential list:
Cervical radiculopathy/itis
Cervical referred
Possible local shoulder injury with superimposed/unrelated neural irritation

Objective: cervical AROM full; slight lower neck pain with R>L rotation, flexion, familiar posterior shoulder/scapular pain with right side bending

Shoulder AROM hypermobile in all directions, pain free with exception of slight anterior R shoulder discomfort with behind the back IR reach; impingement testing negative

“Burning” in shoulder region on right with roos

ER/ABD/IR MMT 4+/5, very mild shoulder discomfort

Pain into right lower neck with right and left mid/lower cervical downslides (normal-hypermobile), mild stretch sensation with upslides

Axial compression in neutral positive for right lower neck discomfort, distraction no change in symptoms

Dermatomes, myotomes WNL, reflexes WNL with exception of decreased R C8 reflex

Median nerve tensioning negative; positive active and passive ULTT-ulnar with increase in symptoms with ipsilateral side bending, no change with contralateral side bending; symptoms were in shoulder blade (not hands or neck)

No palpable tenderness

Initial treatment: explanation of findings, general advice to watch posture, neck positions, craniocervical flexion in supine, supine thoracic thrust , supine ulnar nerve sliders (non tensioned)

Primary hypothesis after objective examination: lower cervical (C8) radiculitis/radiculopathy

Questions:
– Additional objective/subjective information you would have looked to gather? Other primary hypothesis?
– Do you assess/correct/leverage patient expectation? How so?
– In your experience, how much does patient expectation influence treatment outcome?

We can of course talk more about the article specifics next Tuesday, however a few things to be considering:
– Research methods that could have been responsible for the lack of findings?
– How does, “therapeutic alliance” influence patient expectations?
– What are some of the major contributing factors to patient expectation?

Note: the primary article we are focusing on is the one entitled, “Thoracic spinal manipulations for MSK shoulder pain…” However, as it is a planned SECONDARY ANALYSIS, I included the original study as it will be referenced and is helpful to have.

I personally found these articles to be harder to digest and comprehend, hopefully we can make some sense and benefit from them on Tuesday.

Attachments:

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[Aaron Hartstein]

Nick,
Nice article selection – should make for some good discussion. I would love to hear some of the other residents thoughts on your patient presentation and your leading questions. I have some insight to offer after taking a look but want to hear others first. With regards to your expectations question can you give us an idea of her personality and what her understanding/expectations were?

Aaron

[ABengtsson]

Nick – great articles and thanks for posting the second one as well!

Just a few questions about your findings to clarify
– It sounds like you were able to reproduce mainly neck and shoulder/scap symptoms. Were you able to reproduce her hand numbness/tingling?
– Are the numbness/tingling of the fingers a primary complaint with the shoulder pain?
– One of the Aggs was “hand use”, which symptom does that aggravate?
– Did you do any sustained compression/distraction/spurling/quadrants or compression/distraction in quadrant position?
– What do you make of the ULTT causing symptoms around the scap and not in the neck or UE?
– Were you able to differentiate between ulnar n and C8 with any muscle testing?
– What position does she sleep in? How does she reposition to fall back asleep? Are the shoulder symptoms what’s causing her to wake up?
– What made you change your hypothesis from TOS to C8?
– (How) did your asterisks change after your treatment?

Lots of questions, I know… Just curious what patterns you saw and what your thought process was. I still find these types of pts very challenging and it looks like she’s not an easy case.

I try to assess expectations with every pt, but the degree may vary. I start by asking if they’ve been to PT before (eval) and sometimes just directly what they expect. I’ve had a lot of highly irritable patients recently and I spent a lot of additional time earlier to educate them on what normal responses to treatment/exercise can and should be, even/especially if it can lead to an increase in soreness or pain. I had a patient today, who has pretty severe LBP with B radicular symptoms and he went to see the spine surgeon this week to go over his MRI. He told me about the appointment 2-3 weeks ago, so I spent a good amount every visit educating him on MRI findings, function etc etc. I was still nervous how he would react, but he came back today and despite having “massive” HNPs, he was still fully on board with treatment.
I have another pt who’s wife is now trying to convince him to get back sx, (min hard neuro signs, main complaint is decreased mobility). He came in convinced he’d have sx within the month and after educating him on what’s going on, he completely changed his outlook.
One question that has seemed to work well for me during my subjective if a pt comes in reporting increased pain/soreness after last visit or with HEP, is asking the pt whether what they experienced was outside of what was expected based on our discussions.

[Nick Law]

Aaron – absolutely would love to try and give you a sense of her personality/what I perceived to be her expectations. She seemed to me to be a rather “ideal” patient, in that though she was relatively dialed in to her symptoms, she was very humble and non assuming and seemed to truly be on board for whatever I thought was best. She did not seem to be looking for a passive treatment, was remaining physically active, and again simply seemed on board to try whatever I thought would be the best solution to her problem. I don’t think she had any firm expectations of what we were going to do coming in. That said, I am not sure I “assess” expectations very well (if at all formally), and would love to talk about how to do that on Tuesday.

Alex: I will try and be as accurate and concise as possible to your questions.

– Yes, I was only able to reproduce her neck/scapular symptoms; her finger symptoms were never reproduced. Her scapular symptoms were certainly her primary complaint, and therefore I was somewhat satisfied that we had repeatedly reproduced and then alleviated this complaint.
– Hand use aggravates chiefly scapular pain
– I failed to include this in the objective portion (got deleted somehow in my revisions), but YES, I did do a right posterior quadrant. Along with right side bending, this immediately reproduced scapular pain. As her symptoms were already produced, I did not feel the need to add further compression. I did not add distraction in that position, and on reflection should have done so.
– I am not certain I could exactly explain how/why the symptoms are scapular based, however this is certainly not uncommon to cervical radic. In fact, in the original article that determined our CPR for cervical radic (see attached, especially chart on p.56), having a chief complaint of pain PRIMARILY IN THE SCAPULAR REGION was a marker for cervical radic. Not exactly sure how/why, but it certainly can be the case. If anyone has a better rationale for how/why radicular symptoms (and not simply referred symptoms) end up in the scapular region, would love to hear it.
– Seeing that cervical involvement was so very clear (SB/quadrant reproduced symptoms, IPSILATERAL side bending increased symptoms), I did not feel the need to try and isolate ulnar nerve vs. C8.
– In came out in visit #2 that patient sleeps prone in full right rotation with elbow near full flexion. Definitely a moment of education and correction. Yes, scapular symptoms were the driver for her waking up.
– C spine seemed so clearly involved to call it TOS. Before the objective exam I expected cervical movements to be non-implicating, which they certainly were not.
– I failed to re-check asterisks immediately after initial treatment. Time was fairly short, and therefore initial treatment was fairly short. Still, it would have been good to have checked the ULTT following the manip. I certainly re-checked asterisks at visit #2 and will certainly discuss that visit soon.

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[Laura Thornton]

Nick,
Great case. I was reading through your subjective and I would have agreed completely on what you had as your primary hypothesis and differential list afterwards.

From my understanding, it seemed to me that during her subjective, she complained of posterior and anterior shoulder pain along with scapular pain that all occurred together. During her objective (and correct me if I’m wrong), you reproduced her anterior symptoms with shoulder testing and her posterior shoulder/scapular pain with cervical testing. I’m not convinced yet that the shoulder needs to be ruled out for at least a contributing factor. I want to look at her scapular movement patterns and endurance. Was there anything out of the ordinary in terms of scapular dyskinesis or hypomobility with scapulothoracic accessory movements? With a history of hypermobility within her glenohumeral joint and I’m guessing some postural abnormalities since posture was one of your treatments?

When you tested her PAVIMs, you reported that she had normal to hypermobile lower cervical downglides but reported pain. Where during this range did she experience pain? Early or at end range?

During your treatment on the initial evaluation, you were somewhat satisfied that you reproduced then alleviated the complaint. Can you expand on what alleviated her scapular complaint since you didn’t reassess any asterisks at the end of the eval?

In terms of patient expectation, this isn’t a strong suite of mine at the initial evaluation. Sure, I give a ton of patient education and explain prognosis and plan of care during the eval and inquire about any questions or concerns, but I’m not so sure if I attempt to assess or influence expectations as much. Maybe it’s the time crunch at the end. For me, it’s more something that I look at over time. If someone is raising serious doubts of effectiveness of our treatment or showing signs of non-compliance, I will absolutely address it but really not until it comes to my attention or causing a problem, which could potentially go against my favor. I’ll be excited to discuss this with everyone!

[omikutin]

Thanks for sharing Nick!

What was your patient’s irritability level? You mentioned that you did a right posterior quadrant test and you were able to reproduce her symptoms. Have you found that reproducing a patients symptoms early on skews following test results? If so how do you go forward in choosing the best objective exams? As well, any particular reason you used the supine thoracic manipulation as a treatment?

Something that I’m finding is how patient expectations influence motivation. As well, finding a comparable sign is crucial. I had a similar case and educated my patient how his neck was causing his shoulder burning pain. I told the patient to work through his exercises and he will see a change, surgery was not necessary.
He agreed to work through his HEP and by session 3 he had improved cervical AROM and decreased shoulder symptoms. If I’m able to reassess the comparable and make a change in function/ symptoms, then I try to use that information as an educational tool.

[sewhitta]

Nick –
As I mentioned before, I love this topic on multiple levels and I think valuable discussion could come from this to help us all, or just me, problem solve to find where and how to incorporate manipulation treatment into practice to achieve the most benefit. The faculty has brought up the topic of when and if consent should be implemented prior to treatment as well and I think this could fall into that topic with a different perspective.

For instance, I would say that I implement manipulation therapy in my practice a fair amount when I feel it’s appropriate. I feel fairly confident in my skills; however, I feel very apprehensive to “pull the trigger” on performing a “thrust” at times, particularly to the cervical spine. My biggest fear is that I surprise the patient to a degree that causes fear in them and I lose their trust. On one hand, I feel like asking for consent could cause fear and apprehension and may come across as a lack of confidence on my part. On the other hand, I want them to have an expectation of what I am about to do. So far I’ve used phrases such as, “this joint feels really stiff, it feels like it needs to pop, I think that would really help you”, etc, and then I just wait for a reaction or response. I’m exploring different approaches to this issue. Maybe I’m just over-thinking it. I realize some clinicians may just go right into performing the technique without warning. But I just feel a need to have an understanding of their expectations of therapy.

I noticed in this article they just told the patient’s they were going to “push” on their back. It doesn’t look like they informed them of the high velocity thrust. I kinda like the idea of showing a video as they did in this study. Maybe a video in addition to providing patients with the “JOSPT patient perspectives”, that were included in Aaron’s (or AJ’s, can’t remember which) presentation, is the way to go. This may be stating the obvious, but I think if we are planning to manipulate, we should definitely be asking the patient if they have seen a chiropractor and what their experience was like if they have.

Does anyone else share similar thoughts? What approach has been successful or unsuccessful for you (residents and faculty)?

Regardless of the technique being performed, providing more positive feedback and exuding a positive outlook to the patient regarding their therapy outcome is extremely valuable more than anything else we do. Maybe in my practice this has been more pronounced as my confidence grows, but this is one of the biggest changes that I have learned from Eric and Mike and have made a priority in my practice. If we could just influence other healthcare professionals to do the same thing, we would really be in business and on track to changing healthcare and dollars spent on healthcare.

[Kristin Kelley]

Hey Nick
Did I miss it or do you know if there were specific aggs producing her distal (forearm/hand) symptoms?
Are her symptoms different on her work vs non-work days and could/did you affect any of her symptoms in real time with sitting postural education?
Did you also educate her on specific work station changes? (chair, desk, monitor, phone…etc?). We have SO many pts who present with postural problems driving so many of their symptoms are hugely contributory with underlying chronic problems that might not be the prime problem but a big enough issue that if you don’t address that, the pt will spend 40+ hours/week in a poor position which inhibits improvements in clinic or w/HEP.

[Aaron Hartstein]

Nice discussion you guys. Continue to work through some of the questions about the case today and tomorrow so that the discussion on Tuesday can be centered on the article itself. Sean, I think you bring up some very valid points about how we go about informing patients about particular techniques and how maybe the way in which we go about this (our attitude, tone, style, etc) may actually be more important than the actual information they receive verbally. At Kaiser the faculty would often say phrases like “is it ok with you if I give this joint a quick stretch?” and they would tell them they might hear a little sound like when you move your knuckle in a certain way but would downplay any audible effects and let them know that the quick stretch is really the important piece and seemed linked to change in the system. Sometimes patients are still surprised by the velocity of the technique and some sounds, which are certainly amplified in the cervical spine given their ear is so close. However, at least you have told them something and not completely withheld the intent of the technique. With regards to expectations about therapy in general I think some would urge to not wait until the end of the first session to ask this. Why not ask this as part of our subjective history intake as this changes our objective exam and treatment no different than asking about a particular aggravating factor or a red flag. There are plenty of textbooks that discuss rapport building and how important this is during the subjective and having this talk (their expectations) is an avenue to start that dialogue. I attempt to do this and then again at the end to make sure that their expectations were met. This seems to open lines of communication and I think also impacts their buy-in, compliance and cancellation/no show rate as well.

[Nick Law]

Thanks so much for everyone’s participation! Love the discussion and trust we are the better for it.

It seems as if I have done a poor job describing the patients symptoms. Her chief complaint is POSTERIOR SHOULDER/SCAPULAR pain that is described as burning/aching. She sometimes feels some anterior/lateral shoulder pain, as well as sometimes medial two finger numbness (the not so comfortable kind of numbness). These symptoms appear related and occur together (not separately), however to repeat the chief pain complaint is the posterior shoulder/scapular pain.

Laura – yes, resisted shoulder motion (IR/ER/ABD) and behind the back reaching caused some VERY MILD anterior/lateral shoulder discomfort. Pain location seemed distinct from her scapular symptoms, however it appeared VERY mild, and seemed to be searching for the pain vs. truly feeling anything. No facial expressions were noted at all. My guess is she would have rated it 1/10. Impingement testing and other shoulder ROM with overpressure failed to reproduce ANY symptoms. Thus, though there may be some degree of local shoulder pathology, it seemed very low down on the list for me. I did not examine her scap mobility – wouldn’t have been a bad idea, not only for determination of potential local shoulder pathology but also generalized movement pattern throughout right upper quarter. Pain was present with bilateral downglides, started at mid range and increased somewhat at end range – that was a puzzle for me for sure. I probably misspoke when I said that I “alleviated” her symptoms – what I mean’t was that I could very reliably reproduce AND THEN TAKE AWAY the reproduction of pain. That is, I put her into quadrant/ULTT ulnar and pain comes on, I take her out of those positions and pain is “alleviated.”

Oksana – My sense for her irritability was fairly moderate at the conclusion of both the subjective/objective exam, but to be honest I don’t think I could defend it very well. I don’t think I asked her how long it takes for her symptoms to return to baseline once they aggravated. Poor job on my part there. At any rate, I felt confident I could push somewhat vigorously to reproduce her symptoms, and at the same time didn’t want to go as hard as I could have given the fact that she was having significant degree of night time symptoms. I used the thoracic manip for several reasons. One was for the simple “pain gating” effect or “manipulation induced analgesia” that can occur. Another is that there are at least two case series in which thoracic manipulation is included as part of a comprehensive treatment approach that was shown to be helpful in treating cervical radic, and also that there is preliminary evidence from a few experts in our field (#vopmtifaculty) that thoracic manip can improve UE neurodynamics.

Sean – I sincerely hope my surprise thrust’s on you in practice are not making you gun shy. On a more serious note – I feel as I am in the same general struggle with you on what I am telling patients I am going to do. At this point, I am still doing more of what the article did (e.g., “I am going to give you a quick push on your back.”) I see pros and cons to greater explanation of the treatment and the rationale behind it. Like everything else as well, it must be patient specific. Some patients will probably benefit from more explanation/verbal & visual description and rationale than others.

Kristen – you did not miss it; I did not at any point during the objective exam reproduce her medial hand symptoms. Also – I didn’t ask about work day/non work day differences. However, that sounds like a GREAT idea to help determine how much sitting posture is potentially driving her recurrent symptoms. I will ask her that at the next visit for sure. As she seemed to come in to the clinic believing that her symptoms were more shoulder than cervically driven, in large part I wanted to bring her attention to the potential effect her posture is having on her condition. That is, I wanted her to start paying more attention to it. I did give her a hand out that I believe Jim Beazell was influential in developing (see attached) and tried to make some general points of advice, however I did not spend much time on it. I certainly will look to address this more at the next session.

Aaron – I completely agree with querying patient expectations as a routine part of our subjective history. This is NOT something I currently do, and in the process of this journal club it has become more notably important to me. We will talk more about how/when we assess patient expectation and how important we find it to be in clinical practice.

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[Laura Thornton]

Nick,

Thanks for all of that clarification. This is such an interesting case! It’s tough because it doesn’t quite fit cervical radiculopathy CPR, the radicular pain into the UE isn’t there, she’s in this subacute stage where it’s not acute and not necessarily in the chronic stage, but I agree with you that it seems like the most fitting with the pattern recognition. I think you did a great job in choosing the initial treatments.

I also agree that the more I read about patient expectations with treatment outcomes of musculoskeletal treatments, the more I regret not addressing this more frequently. Unlike other measures, this is something we could easily ask about and assess on an individual basis because it’s so specific to each patient. I hope we can also touch on what you all have successfully done in the case of someone who does not expect any positive outcome of physical therapy in general, say someone who is only going through a “round of PT first to be able to get my MRI”. They might show up to every session, but it’s probably going to make a huge difference in outcomes if they don’t believe it will help.

[Laura Thornton]

Interesting research I came across in this review article listed in the references of Nick’s article: Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain. Phys Ther. 2010 Sep; 90(9): 1345–1355.

Physiological Response

Studies of physiological responses that accompany expectation have been reported primarily in the placebo literature. Specifically, studies of expectation-related analgesia have demonstrated associated responses, including activation of the opioid system, changes in spinal reflexes, and specific activation of the brain and spinal cord. Price et al observed a significant decrease in brain activity, as measured by functional magnetic resonance imaging, associated with expectation-related analgesia in brain regions related to pain (thalamus, somatosensory cortices, insula, and anterior cingulate cortex).

Additionally, Craggs et al studied brain activity associated with expectation-related analgesia using functional magnetic resonance imaging and observed sustained activation of regions involved in pain modulation, such as the medial prefrontal cortex, posterior cingulate cortex, bilateral aspects of the temporal lobes, amygdala, and parahippocampal cortices. Furthermore, transient activation was observed in areas of the brain associated with emotion and information processing, such as the posterior cingulated cortex, precuneus, rostral anterior cingulated cortex, parahippocampal gyrus, and the temporal lobes. Finally, Goffaux et al observed a significantly diminished withdrawal reflex, as measured by the R-III reflex, corresponding to expectation-related analgesia. Together, these studies suggest very specific neurophysiological mechanisms related to expectation at the level of both the spinal cord and the supraspinal structures.

[Nick Law]

Laura – thanks so much for posting that article. Truly a very great follow up to our journal club on Tuesday – touches on a great many points that I have been thinking through for the past several weeks. I certainly recommend it to others.

As I read the article, an idea came to mind about how to assess predicted expectation that is even task specific. The patient specific functional scale is an easy assessment to administer, simply asking the patient to rate how difficult any given task of their choice may be. In addition to asking them how difficult it is RIGHT NOW, it would be very easy to simply ask them to rate how difficult they expect the same activity to be in 4 WEEKS. Seems like it would be one way to potentially assess predicted expectation for specific tasks in a quick and easy manner. See my example of what this might look like for a patient with relatively good expectations. Thoughts?

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[Kristin Kelley]

Hey Nick
not a bad form…definitely focuses on function and specificity of patient centered goals and provides some great objectivity to track for both PT and patient. BUT, I feel patients are so overwhelmed with the amount of paperwork we already require of them upon intake that this may be overkill. if we’re collecting a good subjective and focusing on patient goals and objectivity of those goals upon history taking, we will already have this in our documentation and have reviewed it with patients and can track his/her progress with our focus on short and long term goals. Others may find this form very helpful but in my practice I think it might be overkill for most patients. would you use it?

[Nick Law]

Kristin,

I completely resonate with the over-kill nature of paperwork. I don’t think the form should be used as part of the first visit, but do think that it would be potentially valuable on a second visit basis. I also certainly don’t think it needs to be given to every single patient either, but do think it might be helpful with patients for whom you suspect may possess a poor predicted expectation.

The main reason I like the form is that it seems to help capture the patients predicted expectation in a quantifiable, non confrontational way. I also think it is a viable measure that can be used to then have further conversation with the patient about (e.g., is there any particular reason you indicated that you don’t think your condition is likely to change?). Although I am certainly no expert in the subject, somehow I see this as being potentially a better way to broach the patients negative expectations than simply asking them straight up, “Do you think this is going to get better in the next couple weeks?”

• This reply was modified 8 years, 3 months ago by Nick Law.

[Aaron Hartstein]

We utilize the PSFS, especially with our Medicare folks as it can be used to help determine functional status and reporting. We find that it is helpful when the outcome of some of the other scales, such as the OPTIMAL (which we use), does not seem to capture the patient’s level of impairment and need for care. The PSFS is not given to the patient on a sheet of paper but it is on our medical screening questionnaire but indicated that the PT will fill out instead of the patient. It is a reminder to ask their goals and limitations with regards to function, which we already do. The only difference is the numerical rating that the patient gives describing their current ability with that task.

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