Oct 2018 – Journal Club Case

[Dhinu Jayaseelan]

Hi all,

Please see the attached pdf for the case information. Answer the questions, and add additional insight/questions/comments/etc to facilitate discussion. We will talk more about this patient, and the integration of research in her care, next week. Thanks,

Dhinu

• This topic was modified 5 years, 6 months ago by Dhinu Jayaseelan.

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[jeffpeckins]

1) Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
– Is she able to link the recent worsening of symptoms to a traumatic event or change in usual activity?
If not:
– History of cancer? Increased pain at night that can’t be changed with change in position? Night sweats? Recent unexplained weight loss?
– Any other body regions painful?
– Yellow flags: fear of movement, anxiety, other psychosocial factors?
– Did she think that a specific aspect of previous PT was essential to her pain relief?

2) Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?
– Yes: MOI, decreased cervical flexion strength, point-tenderness/ myofascial TPs
– No: no referred shoulder/UE pain, no dizziness/nausea, HA, etc
– I believe she would be a better fit in the “neck pain with mobility deficits” category.
— Central pain, limitation in neck motion, limited cervical ROM, neck pain at end ranges of AROM (however not PROM…), C and T hypomobility, motor control deficits

3) Do you see any red or yellow flags associated with this condition?
– Yellow: fear avoidance (not wanting to drive), multiple PT treatments, was in cervical collar for 4 weeks, “always has pain”

4) What concerns do you have about the patient’s current presentation and previous treatment?
– Lots of passive treatments, depending on how much exercise she did
– Has she been given an HEP from previous PT, and if so, did she attempt that before she sought out PT again?
– She has never completely resolved her symptoms back to baseline
– Worsening symptoms even through there doesn’t seem to be any recent traumatic incident or reason for the increased pain (i.e, driving more often, longer work days, increase in activity)

5) What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
– 1st: Cervical AROM in non-painful ROM (or minimally painful if non-painful not possible) which will likely be supine
– 2nd: Education and advice regarding the necessity for continued movement and exercise (especially aerobic such as stationary bike)
– As quickly as possible begin including mobility and strengthening exercises, not relying very much on MT and decreasing amount of MT time

6) Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?
– Wouldn’t do Grade-V mobilizations due to osteoporosis status

Additional Discussion:
– I think determining the patient’s thoughts and beliefs about why she is in pain, why the pain keeps coming back, etc would be helpful. She seems to have some yellow flags that are concerning and likely inhibiting her recovery. I would bet that she is hyper-focused on her pain and thinks that something is anatomically wrong with her following the MVA four years ago.
– Research has been shown that education is very helpful in patients suffering from WAD. What education would you provide this patient and how would you reassure her that she will get better? (Side note: this is assuming that we would categorize her in the WAD category, but I’m sure this is helpful regardless of categorization)

[Jon Lester]

1) Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
a. Fosamax – dosage, how long, compliance, recent inc? – Common side effect is joint/muscular pain
b.I’d like to know more about previous PT. Why did she have to return 2x/year for 4 years? Did she have resolution of symptoms and then they came back? Or was it a financial/insurance reasons? Could give us an idea of expectations. Also what part of PT that she believed helped the most would be nice to know when planning POC.
c.How did they rule out fracture? MOI alone would warrant an x-ray at that time (Canadian C-spine rules) but doesn’t mean we can assume one was performed. Hx of osteoporosis is concerning as well. Also, does she notice any “clunking” with cervical movements, feeling of “lump in throat” or any other subjective c/o that might indicate ligamentous disruption? MRI might be better choice in this case.
d.Recent increase in symptoms – was there another mechanism that caused this? Or is this how her normal pain fluctuates (PT 2x/yr for 4 yrs)? Additional, seemingly minute, trauma to a previous injury could be more deleterious in someone with osteoporosis as compared to those with good bone density.
e.How often does she receive imaging for bone density (i.e. DEXA scans)? Any changes since the initial injury? How has it trended since starting vit D and Fosamax?

2)Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?
a.Yes I would consider this a WAD presentation with associated mobility and motor control deficits. The underlying condition is likely WAD because of MOI with motor control impairments present (stretching of DCF causing inhibition with cervical movements), which is common with similar trauma. This improper motor control could possibly have led to compensation of the facet joint capsules to “tighten up” and limit motion via non-contractile contribution. This could possibly be why this case could fall into either the neck pain with mobility deficits or neck pain with movement coordination deficits based on how you interpret it. The objective findings show that both classifications are likely present to some degree (hypomobility + pain at Csp facets and inability to activate DCF). It’s a bit of a chicken-or-the-egg conversation and I could see both sides.

3) Do you see any red or yellow flags associated with this condition?
a.Fear avoidance with driving
b.Worsening of symptoms – especially without mechanism at point of worsening
c.MOI with hx of osteoporosis
d.LOC at initial injury
e.Cervical “manipulation” in previous PT
f.Somewhat failed PT because she was unable to maintain improvements on her own (PT 2x/yr for 4 years)

4)What concerns do you have about the patient’s current presentation and previous treatment?
a.Current Presentation
i.Worsening of symptoms – inc in fear avoidance
1. Also worsening without obvious MOI – possibly more sinister implications (e.g. tumor)
ii.Inability to activate DCF
iii.“Worst pain 8/10” and NDI 44%
iv. Hypomobility for B UPAs throughout all mid-cervical (not that concerning but more difficult than one sided or less levels)
b.Previous PT
i.Cervical manipulation in patient’s age group, with hx of osteoporosis, with fear avoidance, and MOI
ii.Dec duration of relief (had to keep coming back to PT) – doesn’t sound like she ever got back to her PLOF
iii.Hard to tell what helped give her some relief (heat vs TENS vs exercise etc) – also sounds like a lot of variations of passive therapy

5)What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
a.Manual Therapy – manual distraction because it was (+) for pain relief, but I could also promote improved joint mobility bilaterally without aggravating either side
i.HEP – Pain-free AROM in all directions – start with NWB if WB is not tolerable
ii.Progression – begin to mobilize both B facet joints with distraction combined with opening joint mobilizations (SB/rot) → then opening without distraction → then eventual closing to improve tolerance to closing movements (as pain permits)
b.Exercise – tactile/verbal cueing to promote improved DCF activation via light chin tucks in supine
i.HEP – light chin tucks over towel for tactile cueing in supine
ii.Progression – chin tucks in upright position → upright position with arm movements → upright position with cervical movements (i.e. rotation to improve confidence/endurance with driving) → eventually add resistance that is pulling out of upper cervical flexion
c.Pt education on how movement won’t cause pain and how it’s important to reduce her symptoms. Also could include some pain neuroscience analogies if she presents in a way that I feel like this would be helpful on her first day.

6)Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?
a.Cervical manipulation
b.Cervical mobilization to promote opening/closing on one side (will cause opposite effect on other side, might be painful)

Additional Discussion
1)Would anyone have tested deep cervical extension endurance? I feel like this would be nice to do in someone who has pain onset after sitting >30 mins (losing battle to gravity). Maybe scapular endurance also?
2)Who would do some form of trigger point release early on in rehab for this person? It looks like she might respond to other more mild forms of treatment but her active trigger points might respond to more aggressive forms of MT also (TDN, ischemic pressure, pinning down with active movement). Just curious to see how aggressive others are during early rehab in those with fear avoidance.
3)Would you implement the FABQ with this patient?

• This reply was modified 5 years, 6 months ago by Jon Lester.

[Jon Lester]

Jeff – In response to your post – I agree that education would be key to her understanding her symptoms and prognosis. I would educate her on the findings that I found that were reproductive of her symptoms (hypo/painful joint mobs, +distraction/compression, dec DCF activation, etc) and how they are all treatable from a rehab standpoint. I would educate her on the length of time I would expect her mobility to improve (gradual over several weeks of directed treatment) and with her motor control/endurance (can take 6-8 weeks to have true muscular changes). My hopes would be to both have her understand that her symptoms are reproducible and treatable, but also that she needs to be an active participant in her therapy. If she was still worried about something being “structurally wrong” with her neck because of the injury, I would educate her on the negative findings that I had that would implicate this to be true (i.e. sharp purser, alar lig test, (-) CN screen). I typically only do this if they press for the information because I feel that some might be concerned that we were concerned enough to look for those things. I’m curious on other’s thoughts on this?

[Cameron Holshouser]

1. Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?

– what type of imaging and positions, any recent imaging?
– what helped / didn’t help with previous PT treatment
– what are the patient’s thoughts on manipulation
– instability red flag questions
– Bone density testing?
– tinnitus, balance, mood ?
– occupation specifics – demands / how long has she been working there?
– ADL’s around the house that still struggle with?
– what activities does / did she enjoy? change with pain?
– What has changed in the past few months to increase fear of driving or has that always been there?
– what type of exercise / stretching / massage location and technique help decrease pain?
– sleeping position and quality
– joint position error testing?
– balance (single leg / unstable surface / eyes closed)
– CCFT ?
– testing rotation with upper trap in slack
– cervical quadrant vs motor control testing

2. Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?

– Yes.
– MOI, very broad symptoms – not just a joint issue
– chronicity, fairly constant,bilateral trigger points in upper shoulder girdle, cervical endurance deficits / motor control deficits, pain with involved cervical segments, increased biopyschosocial / kinesiophobia

3. Do you see any red or yellow flags associated with this condition?

– Red: osteoporosis with mechanism, instability / laxity ?
– Yellow: fear, avoidance, perceived disability

4. What concerns do you have about the patient’s current presentation and previous treatment?

– Current presentation: worsening / no change
– Previous treatment: manipulation, no change in symptoms, frequency ? 2x/year ?

5. What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?

– Depends what her perception of what worked in previous PT sessions, take into consideration
1. education of pain, prognosis, plan of care, reassurance
2. symptom / pain reduction with manual therapy
3. active motion
4. aerobic exercise
5. relate exercise to patient goals (mimic driving)

6. Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?

– manipulation (osteoporosis, older female, fearful)
– immobilization collar (chronic, increases fear)
– heavy resistance training (movement/endurance/pain relief are goals)

[Matt Fung]

1) Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
• I would also like to know when her last bone density scan was considering her history of OP. How long has she been dealing with this condition?
• Was there any other acute incident she can recall that could have led to her increase in symptoms and increase in fear avoidant behavior? Depending on the severity of her OP rolling out of bed could be a cause to a more serious condition.
• I would also question her further on her past PT experience and determine her expectations for treatment. I would like to understand her compliance and what led her to continue treatment for a similar issue for over 4 years
• I would like to know what she does for work, how long is she sitting for what hours is she working to get a better idea of how that could affect her symptoms, Additionally, I would like to know what her resting sitting and standing static posture look like.
2) Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?
• Yes, I would consider this person to fit the WAD based on the MOI, positive DNF endurance test, and reports of loss of consciousness at initial injury. She also meets criteria for neck pain with mobility deficits based on her current presentation. She does not check off all the boxes for either presentation due to the lack of referral pain into the shoulder or headaches, but her initial accident occurred 4 years ago and we do not know if she was having any of those symptoms in the past that have been resolved or improved.
3) Do you see any red or yellow flags associated with this condition?
• Yellow flags: pt demonstrates worsening symptoms without MOI, fear avoidance behaviors with driving, long duration of PT for similar issue with some pain relief, but never returning to PLOF, always has pain
4) What concerns do you have about the patient’s current presentation and previous treatment?
• Age, PMH of OP and insidious onset of worsening symptoms
• Always liked PT and sees some benefit over the past 4 years, but reports that she has never completely resolved her symptoms, what are her expectations with this stint of PT – continued passive modalities?
• Moderate perceived disability on self reported NDI
• Fear avoidance behaviors with worsening symptoms
5) What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
• First treatment option would be education – she has had PT in the past with many passive modalities but continues to lack the ability to active her DCF for prolonged periods of time. I would address her static sitting posture at work and attempt to create a change in pain presentation where she appears to be a large aggravating factor. I would educate her on a posture to encourage dec upper cervical extension and increased DCF activation.
• Second treatment option would be to improve her pain free Cspine AROM so that she can feel more comfortable with driving and being more independent in that aspect of her life. Through a combination of manual therapy and exercise, address her myofascial trigger points and joint hypomobility. Cspine distraction and STM to her active TrPs.
• Progress to joint mobs Gr-II to dec pain levels and teach her gentle chin tucks for improved DCF activation.
• Regress – mobilize Tspine if she cannot tolerate treatment to Cspine currently due to pain  Supine on ½ foam roller with UE movements to mobilize neural system
6) Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?
• Cervical manipulations due to age and history of OP

Additional discussion:
Based on her current worsening presentation (fear avoidance behavior) and her lack of success with PT despite her duration in care, and self-perceived disability would this patient benefit form a top down bottom up pain talk?

[Erik Kreil]

All great points made prior.

1) I’d be interested in her proprioception. If available, it could be helpful to place a laser pointer on her head and see how well she recognizes how far she’s actually moving. There’s decent evidence to suggest that pain is a protective response based on perception – at this point, we’d assume any “damage” from the initial injury would have been healed long ago. (Check out this research study: Bogus Visual Feedback Alters Onset of Movement-Evoked Pain in People With Neck Pain by Harvie, et al in 2015).

2) I love the idea of WAD as an umbrella term for the spectrum of rehabilitation she’s sitting in. This patient has an apparent disconnect between her magnitude of injury and magnitude of disability, exhibited by the difference in AROM vs PROM restrictions noted. Thinking about that more, I’d be interested to know the test position for AROM. If seated, I wonder how she’d perform if her head was supported, such as rotation with the starting position supine head supported by pillow?

3/4) Her description of why she’s in your office screams yellow flags to me. She wanted it to be known that she was hit by a “drunk” driver going really fast (40mph). It’s likely, and reasonable, that she feels wronged and feels that she deserves care and comfort. Being placed in a cervical collar for a full month seems long considering fracture was ruled out, and it’s reasonable to assume this contributed to her perception of being disabled adding to her idea that it’s dangerous to move. Her longstanding history with the prior PT is interesting, and I’d worry that a majority of his approach was from a passive care perspective rather than one that is empowering.

5) I’d start with a Pain Neuroscience Education talk. After 4 years, it’s reasonable to feel comfortable with the fact that all prior tissue damage, if any, is now healed – and yet the patient is still fearful of moving. It’s important to reframe her thinking of what might be harmful and what the pain signals are really telling her; she has more control of her situation than she thinks. Next, I’d begin by working with her to really map out what she’s capable of. Supine, supported upper quarter isometrics; can you turn use the muscles without pain or limitation? Supine supported head A/AROM; can you move without pain or limitation? Proprioceptive work can be really powerful here. Even without a laser pointer, the PT can have the patient close their eyes to take away the visual input and demonstrate A) the patient can move farther than they think, or B) the patient isn’t moving as far as they actually can, indicating they’re holding themselves back. She’s used to years of passive treatment, and objective examination shows indication for benefit from manual treatment so this should be included too but not as a primary treatment emphasis. Progress the treatment by taking away support, or regress it by adding cuing and assistance by PT.

6) I’d stray away from anything stimulating, vigorous, or fast-paced. Slow, static<>minimally dynamic movements will probably be a best approach to bridge the gap between her perception of injury and disability magnitude. Modalities might be a good entry way into her buy-in to feel familiar, but this should be phased out quickly or emphasized for home pain management strategies.

[Caseylburruss]

Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
In addition to what other people have said based on prognostic factors of chronicity:
-I may want to give the hyperarousal subscale. It comprises of five items that evaluate the frequency of symptoms including: having trouble falling asleep, feelings of irritability, difficulty concentrating, being overly alert, and being easily startled. This could help with driving my decision making based on prognosis
– Inquire about headache at inception of accident
– Preinjury neck pain
– Inquire about low back pain at inception of accident
-Sensitivity to cold
– Concussion questions? Did she have one? What were he symptoms directly after the accident? Was she followed by Neurologist?

5) What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
Based on the fact this patient has minimal irritability “immediate resolution of symptoms with cessation of aggravating activity” I think postural education and educating her on this will be huge. Less aggravating activity less pain.

I also may also print off this integrated biopsychosocial model describing potential mechanisms for the onset and maintenance of persistent pain and disability following acute trauma. And discuss her presentation and how it applies to this cycle of chronic pain. https://www.jospt.org/doi/pdf/10.2519/jospt.2017.7455

Bunketorp et al., found that self-efficacy, a measure of how well an individual believes he can perform a task or specific behavior and emotional reaction in stressful situations, was the most important predictor of persistent disability in those patients.

May want to think about a multi-disciplinary team for this patient. Behavior, pain and cognitive therapy options.

• This reply was modified 5 years, 6 months ago by Caseylburruss.

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