[Myra Pumphrey]

Brett – Thanks for posting this interesting case. Just to clarify, you had findings of:

hypomobile PAIVMS C2/3, C4,5 on the left,

asterisks PA/Sideglide to C4/5 = 4/5 pain on the right. This was with P/A left? Sideglide left?

What were your findings with PAIVMs to C2/3 and C4/5 on the right?

Thanks!

[Myra Pumphrey]

Sorry I am also late to comment due to travel. Just a couple additional thoughts. Oksana, you noted that Slump was negative on exam, so I thought you examined this in detail. What were the specific findings? Also, you said that you treated with hip distraction. What were your clinical findings that influenced you to include this treatment technique?

[Myra Pumphrey]

Hi all – Today may be my last posting for a while as I am headed into the Canadian Rockies tomorrow!

I agree with all that there should be some level of caution due to the history, but, as pointed out by many of you, the features do not really fit with instability. Also, much of the description by the patient’s Mom is a bit ramped-up compared to the daughter’s description of the symptoms and history. It would be easy to get wrapped up in Mom’s fear, but a fully active child who does not hesitate to move, never hesitated to move did not give me a high level of concern. The only symptom that concerned me was the ringing in the ears. Interesting,….during instability testing for R Alar ligament, the patient stopped me from doing the test by grabbing my arm with her right hand. All other tests were negative. This gave me significant concern, but surprised me based on the rest of her presentation. I questioned the patient about what she felt and why she grabbed my arm. She said she did not want me to touch her ear (she had been through many uncomfortable exams of her ear over recent months and became fearful of exams. One of the first things she asked me when I came into the room was ‘are you going to look in my ears?’). I moved my hand placement and repeated the test and the test was negative. For sure, we will continue to monitor her ringing in the ears and if she does not improve quickly with treatment, we should order additional testing. On day one, I did some gentle STM and joint mobilization, gr. I, progressing to IV- for hypomobility in the right upper cervical region. Upon reassess, her rotation was improved, no pop. Upon talking to the pt’s Mom on the next day, she noted improvement from the first treatment that was lasting into the next day.

If we became more concerned about instability, what other diagnostic tests may be helpful? M

[Myra Pumphrey]

Thank you for your thoughts! As it turns out, the patient’s had a ‘knot’ in the right upper cervical region after her surgery. She also had some mild discomfort in the upper cervical region which improved within a week. The Mom asked the ENT about the knot and the ENT brought up the concern about Grisel’s. He ordered a CT which was negative for any asymmetry but they saw something in the R upper cervical region that they thought may be consistent with an infection. She was then treated with antibiotics. She never had torticollis. She had no other complaints w/ clearing questions for headaches, symptoms related to cranial nerve, spinal cord or VBI, except, she did have intermittent ringing in the R ear which was present prior to surgery and was improving gradually since surgery. She said there is no relation of ringing in the ear to head movement. I will continue to monitor this symptom closely. When asked, her Mom said the ENT said this is typical for her symptoms which lead to adenoidectomy. When I asked the Mom if the doctor thought she had Grisel’s Syndrome after the CT, she said ‘Well,…no’.

The patient has been fully active since her initial recovery from the surgery and has had no hesitation to move her neck or play with her friends.

More on the findings with instability testing later…

From what you know so far, do the features fit for instability?

M

[Myra Pumphrey]

Hi all! Excellent discussion! This patient has been very very interesting. I commonly see reproduction of lower quarter symptoms w/ assessment of the thoracic spine, usually when the PT is just pushing well beyond the end range of the segment tested and moving the lumbar spine, but in this case, reproducing a very specific L/S pattern of symptoms from the mid-thoracic spine with very specific central PAIVM in the M/T spine (with consistent response) was pretty bizarre. I was definitely thinking about T4 syndrome (:\), but even more, about Butler’s discussion about tension points and the presence of a ‘double crush’ influence from the t-spine, especially after the emerging thoracic history.

I appreciate the comments about close reassess of the neurological findings – I don’t think that point can be emphasized enough. The consistent reassess of the neurodynamic testing is also an important barometer. Also, in regards to referral to an MD – If this patient was not already being followed by an MD, I definitely would not wait at all. I would start the process of an MD consult, so, if the signs and symptoms deteriorate, or return, the patient is already on the path to further diagnostic testing and establishing a relationship with someone who can get the ball rolling on ECI, or surgery, if ever indicated. I am careful to not be too dramatic about the suggestion, i.e., avoiding feeding fear, but I think it makes good sense.

A couple more points.

I believe the ECI plus PT was shown to have better outcomes than either alone, but don’t recall the results being ‘great’ (that was just Laura having a positive impact on the patient’s psyche!). We will find that study and post it for further discussion.

Also, it is an important role that we play in monitoring the patient’s neurological status so closely. It is a great thing that we are seeing the patient more frequently and can reach out to the doc if the situation starts to rapidly regress. If not for P.T., 3-4 weeks may go by between reassessment of the + neurological findings.

In addition, the communication and relationship with the MD is important! This guy had an EMG and we are scratching our heads about the neurological status and prognosis and don’t have the EMG results. It is important to call the MD and discuss the case. The MD who performed the EMG may have a perspective that would be very helpful and all the best for the patient if the medical team is in communication. Laura will have more on that.

… If a week or two goes by and you have not discussed a case with an MD who is co-treating a pt. with you, pick up the phone. You will learn a lot, they will learn a lot, and the patient will be receiving better comprehensive care.

As Laura mentioned earlier, this pt. was convincing himself to have surgery because he was anxious to get back to vigorous exercise and was losing patience. The point I try to make is that surgery is not like a fast food pick up..you don’t just drive to the second window and pick up your return to full activity. Many believe this is the case. By starting some more vigorous exercise w/ emphasis on neutral spine/no increase in symptoms/emphasis on strengthening w/o increased vertical load on the spine, Laura was paralleling with his goals/concerns and he was able to move on from the mentality of ‘I need surgery so I can exercise’ (not to mention all of the other benefits to adding the exercise…)

[Myra Pumphrey]

Hi all! Great discussion! After reading Adam’s rant, there are many points we can discuss about his blog, but here is just one:

1. He did not mention the value of assess/reassess. My question is, are you using this in your practice and are you noticing that certain techniques/vigor/direction of movement are resulting in different results with everything else the same (interaction with the patient, position of treatment, same session, etc)?

In regards to the bodyinmind.org post: These perceptions can be difficult to change and can have many influences that are deeply embedded in patient’s craniums. I may have mentioned this before, but I learned this the hard way after seeing a patient, spending a great amount of time explaining that the patient did NOT have one leg longer than the other, and was not ‘out’. She wrote this in a google review about 30 minutes after the treatment.

… The physical therapists are so thorough and look at your body as a whole not just the issue you are there for. … My son was also having an issue with his knee and one leg was longer than the other. The physician prescribes PT and after several visits, Myra found that his sacroiliac joint was out of alignment and he has not had a problem since.

I believe that manual therapy skills/specific techniques are often a BIG piece to the puzzle, but have always observed that the connections that PT’s make with patients are also important. Here is another statement in that same google review that is likely an important aspect to this family’s outcomes in PT:

… I am so thankful to know they are here when we need them. Thank you all for all the care and attention you have given myself and those I love and care about over the years, I cannot imagine where we would be without you!

I don’t think this aspect of care can be underrated, which is part of the reason I think social history is an important first line of questioning in a subjective exam. I get age, work, kids, and sometimes what their kids are doing in my subjective and often spend time talking with patients about their lives as I work with them.

As for all of the crazy perceptions about patient’s being ‘out’, ‘out of alignment’, etc, I think we need to be very very careful about the things we say to patients to try our best to make inroads to decreasing fear and misconceptions. In the past week, I have had a patient tell me a chiro told them their vertebrae ‘flips in and out’ and had two patients call with questions/worry about a PT telling them that they had one leg longer than the other. In any given week, I have a few who tell me their pelvis is out and that a PT has put it back in to resolve their pain.

Laura – I liked your comments about things you say to try to explain your findings to patients.

Anyone else? What kind of wording do you use to try to decrease fear and give the patient a more realistic perpective of what may be happening when they think they are ‘out’?

[Myra Pumphrey]

Wow – Great discussion all. I am overlapping with many in my comments but in looking at the three articles and the discussion, I think about a lot of PNF concepts developed in the 1940’s. Aaron’s article makes the point of quality vs. quantity with cognitive effort for best neuroplasticity. Many good points have been made that provide addition facilitation of quality of the movement pattern to the original article. Kudos to all of you. I believe the best outcome occurs when you use as many types of facilitation as necessary to achieve the desired pattern. As the patient improves, less facilitation is needed. Early on, I use more facilitation techniques, including manual resistance . Facilitation techniques include:

Visual: (examples include: mirror, having the patient follow their hand through the entire pattern of movement with their eyes and functional visual goals such as reaching for something),

Verbal: (I think cues work better when they are oriented towards what you want them to do, as in Eric’s posted article, rather than what not to do, as when telling a patient to keep their shoulder away from their ear). Don’t forget to use timing and change in tone of voice with verbal cues to influence the best pattern of movement.

Tactile: Tactile and visual cues influenced the change in emphasis noted in the towel slide in addition to the resistance provided by keeping the towel on the wall.. As noted by Laura, specific tactile feedback on the scapula can be very helpful. I think the actual tactile cues of the foam roller (although the scapula is more free, often, you have some scapula contact by mid-range of the movement pattern) or lying supine are facilatory for the scapular retractors.

Progressing through developmental positions: Starting supine is great when the patient has a hard time stabilizing the scapula, then to sidelying (scapula free, requiring more work), then prone, adding gravity as resistance. Then progressing to more difficult developmental positions…kneel, 1/2 kneel, stand, standing on foam. If the pattern is not good, use moving down this sequence as an important tool.

Resistance: Key here is, as noted in Aaron’s article, not having so much resistance that the patient moves out of the desired quality of the pattern of movement. Also, if you are not satisfied with the movement pattern, think about improving the direction of resistance, whether you are providing manual resistance or pulleys or a band. I recommend using PNF patterns for optimal facilitation. If using manual resistance, stand on the diagonal and sufficiently move out of the way to allow movement through the pattern. Give resistance in ALL components of the pattern. If they need facilitation of weak scapular stabilizers, facilitate with one of your hands on the scapula. Carefully think about your hand placement. If using a pulley, position the patient on the diagonal.

So many tools in your toolbox!

[Myra Pumphrey]

Hi guys – I have had a lot of conversations with my surgeon about this (I had a right, then left posterior approach THR in 2014). First, I think there is some incentive to decrease precautions and limitations if they are not indicated because these are the main ‘con’s’ to the posterior approach when competing with the anterior approach. I have a great deal of respect for my surgeon. He is nationally known and all about the evidence, great ethics and best outcomes. He is strongly contemplating changing the precautions at VCU (He is head of the department). He says these precautions were created in the 60’s and the THR has changed significantly since that time. The hospital pre-op class, the PT’s in the hospital and the home health PT’s continue to follow the precautions, but he believes they are much too conservative. He came into my room on day 1 after the surgery and adducted my leg well past midline. From my experience, I believe (i.e., no evidence, just personal experience!) it is the combined position of flexion/add/IR that puts the posterior approach pt. at greatest risk, not any of the motions in isolation. When I am working on improving flexion, I have patients rock in quadriped in relative hip ER to decrease risk. I also believe it is helpful to teach patients the concept of end-feel and educate them to avoid pushing into resistance in combined movements. In addition, I think having a surgeon who repairs the deep hip rotators and comprehensive PT to strengthen all layers of hip musculature likely significantly decreases risk for dislocation. My surgeon agrees. Unfortunately, one study shows that, with the anterior approach, 25% of patients end up with a torn deep external rotator during dislocation for surgery which is not repaired. This was one of the main reasons I chose the posterior approach.

Another opinion: Many surgeons and PT’s tend to take away assistive devices when the patient does not have adequate strength to ambulate in normal biomechanics. I would rather keep them on the AD a little longer if using the AD helps to facilitate normal dynamic strength in normal biomechanics.

Would love to see some research on dislocation incidence in those with less conservative precautions…..

[Myra Pumphrey]

Thank you Laura – He is 65. Other thoughts?

[Myra Pumphrey]

Thanks for posting about this interesting patient Laura!

I saw this patient on day 1, Laura and I saw him on his second visit. I have the advantage of having his EMR up at the same time I am posting so here are a few more details:

Complaints: L SIJ (+Fortin finger test), L lateral hip (deep), L lateral leg. Pain in all 3 areas. He is’ aware’ of the L/S and L L/L region.He also has numbness, C, NV, entire L lateral thigh. No symptoms below the knee or on contralateral side. No c/o headache.

Agg factors:

Upon first getting up to stand after sitting. Walking is o.k. He hasn’t walked prolonged recently, but since the onset, if he went for a 2 mile walk, he would have delayed increase in pain.

He stopped running 2 weeks ago due to incr. pain during running. He played tennis last week and had increased pain after.

Getting in and out of the car: He has to lift his left leg (Pt. is tall and also tends to flex his cervical-lumbar spine to get into the car) due to pain.

Standing for a few minutes increases pain. He is worse first in the morning.

Ease: Lying on right side, sitting, unloading on grocery cart when shopping.

Additional Asterisks:

*Weak hip flexors on the side of the symptoms w/ myotomal testing (left), 3+/5, slightly improved on day 2.
*on day 2, numbness on the lateral thigh was increased when palpating the direction and depth of greatest restriction of soft tissue at site of the hernia repair.
*Flexion was limited on day one at less than 50% with increase of left lateral thigh numbness.
*Extension was limited to 25% w/ increase of left lateral thigh numbness
*Slump incr. thigh pain at -25 deg. knee ext on the L, no incr. w/ neck Flexion or DF
*SLR L incr. thigh pain at 55 deg, incr. w/ neck flexion and dorsiflexion.
*Femoral nerve slump test, noted by Laura above, was much more significant for reproduction of symptoms.
Hip and SIJ clearing exam = negative

Recent History (Initial Evaluation on 11/10) – He was taking the sails down on a 47 feet sailboat the weekend of Oct 2nd, due to a hurricane. This involved a lot of reaching and pulling from combined movements in extension and flexion. He also did a lot of lifting that day and noticed a gradual onset of symptoms during that day (L lumbar to L lateral thigh). He was supposed to run a 1/2 marathon on the 14th. He tried to run twice after the episode and got really severe pain in his back and L hip/thigh. Now, the past 24 hours, significantly less pain, but numbness on the outside of the L thigh. It did not keep him out of work (deskwork), but the pain awoke him, every night for the past 10 days, difficult to RTS.

Past History: 2 previous episodes, one was also since the hernia repair (’09), 18 months ago ago, onset with pulling himself out of a kayak, reaching above for a ladder at a dock into combined extension and contralateral sidebend/rotation. Both previous episodes resolved spontaneously without treatment, but with rest/decreased activity for weeks.

Previous episode, 16 years ago, worse then. He could not get off of the couch for 2 weeks. He was treated with ECI, lumbar, unknown level, and P.T., including traction. Symptoms resolved.

Findings from recent x-rays – DDD, OA of lumbar spine.

Steroid dose pack – Finished 1 week ago. He said it ‘helped marginally’.

Day 1: P/A unilateral left upper lumbar // After treatment: Slight improvement in symptom-free range of motion into extension and flexion. Gapping mobilization of upper lumbar left // decreased paraesthesia at rest, slight additional improvement in symptom-free range of motion into extension and improved lumbar range of motion into forward bend to 75% after treatment (much better improvement with gapping mobilization), increased ROM into SLR, no change in hip flexor testing. On visit 2, we needed to bring him into extension quadrant to reproduce symptoms, his improvement into flexion was maintained, he was significantly improved for the rest of the day and the night of treatment. On the second night after treatment, he awoke with significant pain/paraesthesia.

Day 2: Besides education on posture modification, we added soft tissue mobilization of the soft tissue restrictions around the hernia surgical site // decreased numbness after the soft tissue massage. We repeated the upper lumbar gapping technique.

Questions:

Meralgia Paresthetica appears to be one probable component. The lateral thigh numbness began only 24 hours prior to coming to P.T. What are the other hypotheses on the list at this point?
What do you think about the history of episode 9 years before the hernia repair?
What other details would you like to know about his past history?
Would you contact his referring physician?
If so, would you note and specific concerns or recommend any special testing at this time? Are there any questions you have for the physician?
If he returns improved in symptoms and all objective asterisks, but not resolved, what would be on your list for possible progression of treatment?
Do you think the physical therapy prognosis is good? Why?

[Myra Pumphrey]

Thanks for posting about this interesting patient Laura!

I saw this patient on day 1, Laura and I saw him on his second visit. I have the advantage of having his EMR up at the same time I am posting so here are a few more details:

Complaints: L SIJ (+Fortin finger test), L lateral hip (deep), L lateral leg. Pain in all 3 areas. He is’ aware’ of the L/S and L L/L region.He also has numbness, C, NV, entire L lateral thigh. No symptoms below the knee or on contralateral side. No c/o headache.

Agg factors:

Upon first getting up to stand after sitting. Walking is o.k. He hasn’t walked prolonged recently, but since the onset, if he went for a 2 mile walk, he would have delayed increase in pain.

He stopped running 2 weeks ago due to incr. pain during running. He played tennis last week and had increased pain after.

Getting in and out of the car: He has to lift his left leg (Pt. is tall and also tends to flex his cervical-lumbar spine to get into the car) due to pain.

Standing for a few minutes increases pain. He is worse first in the morning.

Ease: Lying on right side, sitting, unloading on grocery cart when shopping.

Additional Asterisks:

*Weak hip flexors on the side of the symptoms w/ myotomal testing (left), 3+/5, slightly improved on day 2.
*on day 2, numbness on the lateral thigh was increased when palpating the direction and depth of greatest restriction of soft tissue at site of the hernia repair.
*Flexion was limited on day one at less than 50% with increase of left lateral thigh numbness.
*Extension was limited to 25% w/ increase of left lateral thigh numbness
*Slump incr. thigh pain at -25 deg. knee ext on the L, no incr. w/ neck Flexion or DF
*SLR L incr. thigh pain at 55 deg, incr. w/ neck flexion and dorsiflexion.
*Femoral nerve slump test, noted by Laura above, was much more significant for reproduction of symptoms.
Hip and SIJ clearing exam = negative

Recent History (Initial Evaluation on 11/10) – He was taking the sails down on a 47 feet sailboat the weekend of Oct 2nd, due to a hurricane. This involved a lot of reaching and pulling from combined movements in extension and flexion. He also did a lot of lifting that day and noticed a gradual onset of symptoms during that day (L lumbar to L lateral thigh). He was supposed to run a 1/2 marathon on the 14th. He tried to run twice after the episode and got really severe pain in his back and L hip/thigh. Now, the past 24 hours, significantly less pain, but numbness on the outside of the L thigh. It did not keep him out of work (deskwork), but the pain awoke him, every night for the past 10 days, difficult to RTS.

Past History: 2 previous episodes, one was also since the hernia repair (’09), 18 months ago ago, onset with pulling himself out of a kayak, reaching above for a ladder at a dock into combined extension and contralateral sidebend/rotation. Both previous episodes resolved spontaneously without treatment, but with rest/decreased activity for weeks.

Previous episode, 16 years ago, worse then. He could not get off of the couch for 2 weeks. He was treated with ECI, lumbar, unknown level, and P.T., including traction. Symptoms resolved.

Findings from recent x-rays – DDD, OA of lumbar spine.

Steroid dose pack – Finished 1 week ago. He said it ‘helped marginally’.

Day 1: P/A unilateral left upper lumbar // After treatment: Slight improvement in symptom-free range of motion into extension and flexion. Gapping mobilization of upper lumbar left // decreased paraesthesia at rest, slight additional improvement in symptom-free range of motion into extension and improved lumbar range of motion into forward bend to 75% after treatment (much better improvement with gapping mobilization), increased ROM into SLR, no change in hip flexor testing. On visit 2, we needed to bring him into extension quadrant to reproduce symptoms, his improvement into flexion was maintained, he was significantly improved for the rest of the day and the night of treatment. On the second night after treatment, he awoke with significant pain/paraesthesia.

Day 2: Besides education on posture modification, we added soft tissue mobilization of the soft tissue restrictions around the hernia surgical site // decreased numbness after the soft tissue massage. We repeated the upper lumbar gapping technique.

Questions:

Meralgia Paresthetica appears to be one probable component. The lateral thigh numbness began only 24 hours prior to coming to P.T. What are the other hypotheses on the list at this point?
What do you think about the history of episode 9 years before the hernia repair?
What other details would you like to know about his past history?
Would you contact his referring physician?
If so, would you note and specific concerns or recommend any special testing at this time? Are there any questions you have for the physician?
If he returns improved in symptoms and all objective asterisks, but not resolved, what would be on your list for possible progression of treatment?
Do you think the physical therapy prognosis is good? Why?

[Myra Pumphrey]

Great discussion and interesting case!

Nick – You made some good points when answering the posted questions about the article. I will be interested to see additional discussion in relation to the questions!

Laura – How long does it take for the bilateral hand numbness to ease after produced with cervical extension. If it takes a long time to ease, would you still test quadrant? Also, did you ask about symptoms on the opposite side during the subjective? Now that you are aware of this area of symptoms, are there other areas you would like to ask about (‘clear’)? Other questions you want to ask? I agree with doing an UMN screen. Interesting that Spurlings was negative….

Great ideas for ways to treat the comparable clinical findings in positions of comfort. What clinical findings would you reassess to prove the value of added techniques?

Re: bilateral numbness with cervical extension, but reproduced with pressure on the palm during ADL’s….what other tests will you be doing to differentiate?

During the Upper Limb Tension Test, Median emphasis, what pain was reproduced?

This wheezing seems significant. Do you feel comfortable with how this is being managed/monitored? Are there specific tests that you feel would be important to monitor related to this? Besides blood pressure, have other medical tests been performed?

[Myra Pumphrey]

Thanks for sharing Nick! Just a thought, it is important to consider the anatomy of this nerve when prescribing the use of an SIJ belt for patients. I warn patients that the belt should feel supportive, but not excessively tight. I advise them to loosen the belt if they start to feel any symptoms in the distribution of the LCNT and to DC use of the belt if loosening does not resolve the symptoms.

[Myra Pumphrey]

Casey, with chronically stiff capsules, you usually have some part of the movement that is resistance-free, then move into motion with resistance, then finally reach the limit of the motion. Often, you have a lot of motion where there is resistance, but no pain. Sometimes, you don’t have pain until you are at the very limit of the motion. It is my experience that if you work into resistance, but don’t push into pain, you can often make significant gains in motion without excessive soreness. You can use the same concept when setting the patient up for their MET for neuromuscular re-education in the motion you have gained with your manual techniques. Pushing into pain often results in spasm which increases resistance/movement limitation and causes more soreness.

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