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Hello all, long time no post. My name is Erik Lineberry, I was a resident with VOMPTI a couple years ago. I was actually in the discussion board to make an entirely different post, but found this case interesting and decided to add my 2 cents.
The power of perception is real and I think the way you handled allowing this patient to dictate their care was appropriate. The way I see it the US is being used to improve the patient’s outlook on their condition and allowing you to add exercise and education that will help. The US time can even allow for a positive conversation about the patient’s condition and care. Healthcare should be collaborative and a patient is part of it. In this situation I guess I am okay with providing the treatment because, even though the physiologic value of US is little to nothing, it is valuable to this patient in other ways. I always feel like while I am not necessarily lying to patients like this, I am not being entirely truthful and it does sit a little weird with me.
Also, I attached a fun article in relation to how perception shapes care and the use of US. I’m interested to know if your patient has experienced the positive benefits of using US with clockwise circles.
I have treated a fair amount of patients status-post MVA with and without WAD. I found the first WAD JOSPT issue to be insightful and was pleased to see the second one came out this past month. Thanks for posting this to finally make me open it up.
One of the things I find the hardest when treating patients with WAD is managing dizziness and nausea symptoms when they are present. Due to this I chose to review the clinical commentary by Julia Treleaven, PhD, Bphty. I thought this commentary did a great job at explaining appropriate assessment techniques and differential diagnoses for patients presenting with dizziness following trauma. The author called for a structured exam that includes cervical joint position sense, balance, oculomotor reflexes, and coordination assessment. The article points out a few times that the symptoms associated with WAD and concussion overlap quite a bit and are often seen as concomitant conditions. Common differentials that warrant referral were vertebral artery in sufficiency and perilymph fistula. I would include psychological presentations as a possible referral as well. This commentary helps to provide structure to a difficult exam for patients with dizziness and/or WAD following an MVA. I added the differentials table for review.
One thing that jumps out to me when reading your cases and reflecting on my own below is the importance of reassessment/reflection and getting a second pair of eyes on the case when needed. I know with my case especially it was something that I should have picked up on earlier and would have if I did a reflection of the case. This is the true benefit of a residency program. It forces us to use tools like the clinical reasoning form for reflection and provides mentorship for complex cases. Keeping this in mind as this rez year comes to a close, it will be important to continue to use the tools/skills learned over the last year and to keep in touch with you guys when a tough patient comes along. I think back to what Eric Kopp said about his time “treating on an island” and can see the difficulty in that when compared to my clinical experience over the course of this program.
One patient I recently saw presented with cervical radiculitis. She had a long Hx of cervical pain and distal numbness/tingling in 4th and 5th digit of RUE. Her sxs had been exacerbated by an UE traction injury at work when attempting to catch a heavy object that fell from her work bench. Her sxs at IE included BL neck pain from mid Csp into her shoulder. She described a pulling sensation at R elbow and increased numbness and tingling in her 4th and 5th digit. These sxs were worst when sleeping. My diff Dx included cervical radic, disc dsyfnc, facet dysfnc TOS, rotator cuff pathology, and trigger point of lev scap/rhomboids.
Objective findings included neck pain with R rotation and extension, R back quadrant increased shoulder and elbow sxs. Distraction eases UE sxs. Rotator cuff was not fully assessed at IE, but ER lag and belly press were negative. Patient was unable to raise RUE from side. Shoulder PROM was WNL, she limited end range flexion and ABD BL. Neuroscreen showed increased C5 and C6 reflexes on R compared to L. Sensation screen WNL and myotomes unable to assess due to pain. At follow up visit pnt had positive findings during ULTT for median and ulnar nerve. Median reproduced elbow pain and ulnar reproduced numbness and tingling in hand.
At this point I was confident that cervical radiculitis was the primary pathology with a probable peripheral traction injury present. I was also keeping an eye on shoulder sxs to monitor for rotator cuff injury. After 3 weeks her neck pain had subsided an her shoulder pain was minimal. She could modulate her sxs at home with head positioning in supine and sidelying positing. I continued to treat postural and cervical impairments, however mild shoulder and elbow sxs remained. Upon reassessment I found supination limitation and radial head restrictions with reproduction of elbow sxs. With functional lifting it was apparent she was compensating for the lack of supination with shoulder protraction and ADD. We treated the radial head restriction for 2 visits and she was back to work without issue. I should have reassessed earlier in the rehab process. I do not think I would have been able to discern any local elbow dysfunction at IE, but radial head dysfnc with a described traction is not uncommon. This was a case of me having my blinders on early on.I do not any go-to self AO or AA mobs unfortunately. My first thought for motor control exercise for the upper Csp would be chin tucks with progressive head nodding and cervical rotation while holding the tuck. Attempting this in supine, seated and prone on elbows positions depending on the pnt’s ability to perform exercise and your goals. I think prone wors well for pnts that just cannot figure out what muscles they are supposed to use, but it can be challenging if their DNF are weak or fatigable.
For the TMJ specifically, I have found that working on control of lateral deviation has been effective for a few pnts starting with the use of a mirror to reduce shakiness of motion. I will progress this to restrictive lateral deviation with the pnt’s hand. I have never utilized a lateral pterygoid release, but have seen this be effective with pnts and it can be given as a self-STM for the right pnt.
As far as hearing changes go, I would love to hear others’ thoughts on this. I have had TMD for years. It has never given me much trouble, but within the last 1-2yrs have noticed more auditory sxs. I have started to worry that it may be time I seriously treat myself to prevent progression of these sxs. If I had a pnt report these sxs and they were not changing with TMD intervention after 2ish weeks I would most likely talk to them about seeing an ENT to rule out big scary stuff and prevent permanent hearing changes.
1. I thought it was a well-designed article overall. A relatively small sample size, but I have found that to be common with TMD articles. I would like to see more studies of this manner that categorize TMD and treat with manual/exercises directed at muscle, TMJ, and Csp or a combination. Studies with bigger sample sizes or a SR would be interesting as well.
2. I have found STM and trigger point release to be effective for TMD with masseter and temporalis muscles. I have treated Csp with every TMD pnt I have seen will good results. What techniques I used depended on the deficits I found with cervical assessment. I also found that lateral glides of the TMJ itself to be effective with the patients I have treated with a unilateral deficit in motion or with mechanical sxs.
3. Attached is a physioedge synopsis I reviewed a few months ago that I found helpful.
4. Were you able to change these sxs with manual techniques or changes in TMJ position just to rule in TMJ as the structure at fault? The biggest concern for me with pnts that have TMD and ear sxs are hearing loss or disturbances. I would monitor those sxs carefully and refer if/when appropriate.1. I have not had any experience with CRPS, I look forward to hearing from others experiences with this condition.
2. Having multiple people involved in a single case always makes things trickier for me. As others have already stated getting buy-in from multiple people can be difficult. The way I approach building rapport with people varies significantly based on a person’s personality. This is true for spouses, family members, parents, etc. It comes down to reading people and understanding if it will be better to explain treatments/POC individually or as a group. Expecting what each member of the patient’s support group will respond to is an important part of care. How were both the patient’s and parent’s response to her condition and your exam/treatments?
3. If the patient is truly declining each visit and I have modified my treatments accordingly I do not think I would continue to treat them without at least a second opinion for longer than 2 weeks. That being said, I think it is important to make sure the patient, parent, PT, and PCP know the expected response to treatment is and what the prognosis is. When a patient has a bad day and you guys have already talked out what to do about it, things will be 100x better than if they have been steadily improving and all of a sudden they have a set-back. I have let that bite me a few times with patients that I knew may have an up and down trend to better instead of a linear one.
4. Everyone needs their T-spine manip’d, it cures all. In all seriousness though, I could see how this treatment may help. I am always concerned about a possible negative response to manipulation in patients with chronic conditions. I have found it hard to build rapport and easy to lose it with these folks. I tend to start gentle and build trust prior to manipulation, which sounds like what you are doing. What Scott mentioned about test-retest hits home for me. If it works, don’t fix it. What has her response been to your thoracic intervention? Do you feel like you are stimulating the sympathetic NS with the physiologic motion you are providing or is there another mechanism at play with this intervention?
I have found that using graded movement/exercise with less heavy pain education has been more effective than using videos and pain explanations with every patient that I think has FM or chronic pain. I think this article backs that up. Unless I am mistaken the participants do not receive any pain science education at all. This has been a shift in my treatment for these patients recently and is mostly due to finding myself talking in circles and having better results giving a very basic explanation of the body/brain being “over-protective” and the exercise providing a means to show the body that movement is not a threat to calm down the protective responses. I will also list to patients the benefits of regular CV exercise including increased blood flow to promote healing, release endorphins, and promote analgesic responses and not even provide any of the pain science education or analogies we have talked about before.
I find it difficult to use the Borg with everyone, but it is highly effective with patients that understand it. If the Borg isn’t going to work, I explain that I want the patient to find a CV exercise that they will do regularly and comfortably. We find a baseline distance or time and try to improve upon this week to week.
When I see patients with FM in their history or patients that have self-diagnosed themselves with something via Dr. Google I have these kinds of treatments in the back of my mind if they are not responding the way I would expect from traditional intervention, but I try not to jump the gun on throwing them in the chronic pain bucket.
Thanks for uploading this, it is a good article to keep on hand and was an interesting read. I love this stuff.As others have stated I feel like I tend to rely on anchoring and premature closure. I find myself latching on to a common diagnosis or the first thing that the pnt’s subj history leads me to consider and losing perspective of other features of the case. Due to this I see myself falling into a frequency or availability bias. This article was a good read to allow for reflection on how I evaluate and treat patients. From what I gathered a big key to an effective eval is to not rely heavily on other provider’s data and to allow time for reflection of a presented case to avoid heuristic bias.
I have been treating a difficult and overwhelmingly negative patient over the last 2 weeks and have had a hard time flipping the conversation from her disability to her ability. Just yesterday we had a long conversation about short term (1-2 visit) goals instead of her long term goals of driving and ambulating without an assistive device. I hope this makes a difference is her demeanor over the course of our future visits.