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Great case! He had no pain during his desk job, that potentially could mean that the LCN was potentially put on slack. His MOI involved lumbar extension and reaching/ pulling which could have caused increased abdominal pressure and perhaps some somatic pain due to prolonged extension positioning. His pain is similar to his past so I’m thinking any sort of pressure on the inguinal ligament is irritating potentially to a peripheral nerve? As well, post surgery scar tissue could be limiting some nerve gliding. What side was his hernia repair? And how long did it take for his previous symptoms to reside?
Hypothesis: You said his hip flexion was 3+/5 (how was his L2 dermatome?) As well how was his knee extension (and L3 dermatome)? He could have a nerve root irritation.?
Progression of Rx: How much tension is on his rectus femoris/ Sartorius? Are they hypertonic? How does his femoral head sit (is it sitting more anteriorly?) As well from the last class we learned to position joints in the least stressful physiological position. What if there was direct treatment when he is place in more extension (SL).
Myra- what was that book called again “Current concepts by Edwards 2nd edition?)
Sean’s idea is great with increasing thoracic mobility, arms crossed over a pillow may help. As well, what were some of the sign’s and symptoms that made you think you treated a T4? It’ll be good for me to keep that in the back of my mind.
Nick- that’s a great video to increase thoracic mobility! Laura mentioned his surgery was 5/2014 and he’s 63. I think that’s a great progression. I’m excited to learn new techniques this weekend.
Something that Kristin is teaching me is to assume that the patient has every pathology present and my goal is to rule the most sever out. IE cervical myelopathy (good call AJ), UMN (reflexes, Babinski, Hoffman), you have a good list you wrote before. He had surgery last year, did he also have previous therapy? If so what did they work on? His wheezing is a concern of mine, I wonder when his BP meds were changed and if that’s when he started feeling the whole hand numbness more prominent?
You mentioned numbness when typing on his computer and driving his car (palm against the steering wheel). Where is his hand placement at 12, 3 o’clock or a little lower on the wheel? Is he at a desk when he’s typing/ how far away is the computer? My assumption is that he probably has forward head with a mechanical stress point at his mid cervical junction. How is his scapula positioned (abducted, downwardly rotated, depressed)?
Going back to your article, STM would be beneficial to tender spots. I agree with Nick, I highly doubt I would see a patient who does not have tender points in the upper quadrant. I also wonder why the sonation time was 50% as compared to a different dose? I also find it interesting that the neurodynamic placement was different between groups. The STM therapist also had the autonomy to spend time on any particular region based on his/her assessment whereas the US group has a strict 5 min cervical, 5 min UE. The article you selected was also from JMMT and I’m sure they would biased any manual intervention is better than a modality.
• How would you address thoracic and costovertebral joint mobility in a patient with preference to sitting, reclined sitting, and side-lying positions only? I have never had a patient post sternotomy but I have had patients who could not lay down due to vertigo. One way I found to assess thoracic motion in sitting is having the patient go through cervical full AROM while observing upper thoracic motion. I also palpate between the SP to see how much thoracic movement the patient has. Side-lying is great for assessing the spring mobility of the costovertebral joints. It’s also possible to do a PA force down the thoracic spine to assess provocation/ joint end feel.
• What other tests would you consider to further evaluate the bilateral numbness with sustained cervical extension? Did you place the patient into different SB quadrants and see if the symptoms changed?
• How would you differentiate between cervical radiculopathy, thoracic outlet syndrome, and brachial plexitis for the burning hand symptoms? Thoracic outlet syndrome we know has a vascular component special test like Adson’s , costoclavicular, etc. would help rule it in/out. Checking changes in radial pulse are vital during these special test. Cervical radiculopathy is typically segmental with changes in a specific dermatome/ myotomal patterns. If it’s truly a cervical radiculopathy I don’t think the patient shoulder have a whole hand burning sensation. Brachial plexitis is typically multisegmental. It depends if the patient has a peripheral presentation or a cord compression presentation. For example, if the patient has a posterior cord compression then I would check MMT tricep, wrist extensors, sensation loss in a radial peripheral pattern. I would also see if there is atrophy present. I don’t know if a burning sensation is common symptom for this, but I would definitely check all the other test and see if that changes symptom.
I have yet to read your article, but I will soon.
The lack of evidence for “premanipulative screening has caused some authors to suggest that identifying patients for whom there may be risks associated with TJM in the cervical spine is virtually impossible and that perhaps the potential benefits may not outweigh the inherent risks. This may explain why physical therapists will report utilizing TJM in the thoracic spine more frequently than in the cervical spine in patients with neck pain,1despite evidence that many of these potential negative outcomes may be prevented through careful examination”. Do you think the reason why many therapist don’t use cervical manips due to potential adverse effects or lack of technique? I mean there are benefits from a T-spine manip. Have you guys seen a case where only a cervical manip was indicated that you couldn’t use the thoracic one?
Puentedura did a study comparing thrust manipulation to the cervical spine as compared to a thoracic manipulation in patients with neck pain. She found “that patients with acute neck pain (less than 30 days in duration) who received TJM to their cervical spine had greater improvements in neck disability (P⩽.001) and pain (P➭.003) at all follow-up times than those who received TJM to the thoracic spine”.
Nick- you bring up an interesting point, I think Cleland is the co-author of a majority of orthopedic studies. I also appreciate what Salmon- Moreno mentions “spinal thrust manipulation to act through the stimulation of descending inhibitory mechanisms, particularly the periaqueductal gray matter. This assumption is mainly based on the premise that spinal thrust manipulation exerts a mechanical hypoalgesic effect, thereby increasing pressure pain thresholds.” I feel as though there is a plethora of articles support thrust manipulations, as long as we clear red flags/ contraindications. Why not? Granit cervical CPRs lack validity but maybe an algorithm is something we should focus on more.
Alex- Great idea on the flat hand technique! We talked about that here in the clinic. I’ve never been able to get the flat hand technique but practice with practice maybe?
Sorry for the confusion from my previous comment. I did a pub med search “clinical prediction rules for cervical manipulation” and couldn’t find a good search. The reason I listed the Lumbar CPRs is because that’s the only CPR that I know prior to a thrust technique. I would think that osteoporosis would be a contraindication for any region thrust technique.
These clinicians should have determined the safety of the technique based on the following contraindications: acute fracture, Acute soft tissue injury, Dislocation , Osteoporosis, Ligamentous rupture, Ankylosing spondylitis, Instability, Rheumatoid arthritis, Tumor Vascular disease, Infection, Vertebral artery abnormalities, Acute myelopathy, Connective tissue disease, Recent surgery, Anticoagulant therapy. The purpose of this narrative review was to retrospectively analyze documented case reports in the literature describing patients who had experienced severe adverse effects after receiving CSM to determine if the CSM was used appropriately, and if these adverse effects could have been prevented using sound clinical reasoning. The statistic shared earlier of 44.8% corresponds to the number of adverse effects that could have been prevented when contraindications or red flags should have stopped the care provider from performing a CSM. These results imply that determining a CSM is indicated in not sufficient to prevent adverse effects. A thorough examination to rule out all contraindications is necessary. Interestingly, the most common adverse effect was found to be arterial dissection.
In conclusion, it is vital to take a thorough history and rule out a VBI, cervical arterial dysfunction. Clinical prediction rules maybe important as listed for the lumbar spine; however, I think it is most important to rule out potential risk factors before implementing a CSM. We learned from our first weekend courses a few CPR for t-spine manipulation for cervical spine dysfunctions. Do you guys think we need clinical prediction rules for cervical manipulations to treat neck pain as well?
Nick- thank you for your reply. Osteoporosis was indicated as a contraindication, and frankly I don’t think my skills are up to par with cervical manipulations. As for activating deep cervical flexors post manipulation sounds like a great idea especially due to the presentation of your patients “forward head”. I can only imagine how shortened those muscles are. Have you tried the deep cervical flexion endurance test?
I actually looked into another pubmed search of thrust manipulation and neck pain and found an article comparing KT to thrust. I think patients who are contraindicated for thrust might benefit from this. Has anyone done this type of KT?
We learned in school 5 criterias for spinal manipulation when it comes to clinical prediction rules: <16 days for the duration of the current episode of low back pain, no symptoms distal to knee, < 19 on FABQ, > 1 hypomoile segment in the lumbar spine, > 1 hip with > 35 degrees of internal rotation (1). We also know contraindications such as: VBI, RA, fracture, osteomyelitis, bone tumors; however, osteoporosis is not a contraindication. I researched “thrust manipulation osteopenia”, “thrust manipulation osteoporosis “ , “HVLA with osteopenia”, “HVLA with osteoporosis” and found 0 hits on pub med. I think that would be an interesting study, but honestly how many sweet old ladies who have osteoporosis would be thrilled to join this study? I’m already speculating a small pull of patients.
I ran into a narrative review done by the American College of Physicians in 2014 and they concluded that if all contraindications and red flags were ruled out then clinicians can prevent up to 44.8% of adverse effects. An adverse effect was defined as “the sequelae following a CSM that are medium to long term in duration, with moderate to severe symptoms, and of a nature that was serious, distressing, and unacceptable to the patient and required further treatment” (2) Absolute contraindications were found to be: acute fracture, Acute soft tissue injury, Dislocation , Osteoporosis, Ligamentous rupture, Ankylosing spondylitis, Instability, Rheumatoid arthritis, Tumor Vascular disease, Infection, Vertebral artery abnormalities, Acute myelopathy, Connective tissue disease, Recent surgery, Anticoagulant therapy. These were found by Dr. Kathryn Refshauge, dean faculty of Health Sciences and Professor of Physiotherapy at the University of Sydney, who quotes “with subsequent research, manipulation may ultimately prove to be effective in the hands of particularly skilled practitioners for a sub-group of patients” (3) Of those 44.8% of AE cases were not screened for contraindicated signs. A thorough examination needs to be done to rule out contraindications and red flags. I would say as a novice therapist, it’s important to abide strictly to these contraindications. I do know a few experienced physical therapist who have done thoracic HVLA on patients with osteoporosis and have received great results.
Mark Jones brought up a great discussion when he compared novice to experts. When do you think it is appropriate to go off of clinical judgement and use HVLA even if a patient has osteoporosis/ penia? If you can’t use a thrust technique what’s another technique to consider? Dunning et al reports non thrust techniques have a statistical significance of improvement (thank you Nick). What other techniques compared to thrust manipulation could we use to help decrease neck pain?Reference:
1. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study. Ann Intern Med. 2004;141:920-928. doi:10.7326/0003-4819-141-12-200412210-000082. Puentedura EJ1, March J, Anders J, Perez A, Landers MR, Wallmann HW, Cleland JA:Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther. 2012 May;20(2):66-74. doi: 10.1179/2042618611Y.0000000022.
3. Refshauge KM, Parry S, Shirley D, Larsen D, Rivett DA, Boland R. Professional responsibility in relation to cervical spine manipulation. Aust J Physiother. 2002;48:171–9
Thanks for sharing Nick!
It’s interesting how Cheathman et al mentions that MP has a higher predilection in adult males while the risk factors are “obesity (BMI ≥ 30), pregnancy, tight garments such as jeans, military armor and police uniforms, seat belts, direct trauma, muscle spasm, scoliosis, illiacus hemotoma, and leg length changes”. In school we learned this condition as the “Britney spears phenomena” due to the common presentation in females. One of my coworkers saw only 10-13 cases over the past 25 years (more female than male with BMI typically > 30). His first approach was posture. Greater than half of these cases his patients were sitting cross legged with their weight distributed over their anterior hip. Once that habit was broken prognosis significantly improved.I would love to hear about your patient’s demographics, MOI, and symptoms. What approach did you take and what findings made you think MP?
Something that fascinates me is how the patient from Beazell started to have symptoms 3 years prior of lateral knee pain which leg length was not addressed. Why would symptoms start right then? I wonder how many years she has been a runner prior to pain starting. It’s great that a heel lift was given to decrease the shear on the inguinal ligament. Brilliant, thanks for sharing!
It was great meeting everyone this past weekend.
Nick- thanks again for posting this article. In class we learned several ways to clear out the shoulder and multiple test clusters to rule in or rule out certain pathologies. I like how this article focused mainly on the principals of consistency through the skills of observation: inter/ intra reliability.Questions:
1) Segarra et al. focuses on maintaining sub-occipital neutral positioning during cervical extension. Maybe they’re trying more to isolate cervical extension while at the same time observing upper cervical stability? Maybe we’re “unloading” the lower cervical spine by decreasing the force potentially that could be caused by vectors from a shearing force if the upper cervical spine was not in neutral? Who knows. All I know is that I want to learn how to collect observational data points. I’m still trying to keep an open mind and potentially learn how to make the best correlations through “maybe related” statements. Regardless, we’re looking encouraging lower cervical extension. This weekend we saw an exercise that emphasized stretching the lower cervical spine in sitting, this maybe a postural cue or it could turn into an exercises or both. In past rotations, I try to think of exercises that patients could do through out the day. Many people sit throughout the day, so why not work on exercises there. My cue would me to sit up straight, apply a superior-inferior force via shoulders, see where they break, find a “neutral spine” position and cue a neutral upper cervical position and “imagine a string tied to the back of your heard and it’s lifting you up towards the ceiling”. Some of my patients loved it (to my surprise). They reported feeling “lighter, stretching, etc”. I would encourage that motion and progress to a hip hinge first in cardinal planes and then multiple plans (maintaining a neutral spine with changes in moment arms). So far that works for some patients and quadruped is a great progression from there.2/3) GUESSE WHAT! I used the occipital release technique (not manip) on a patient today and she LOVED it (making friends.. great).. I backed tracked today and I gathered some more subjective information. My first thought was “hypermobile, floppy neck, duh… stability (what a rookie mistake)”. Her pain presentation seemed somatic in nature and followed the C2/3 referral pattern. My focus on this severely irritated in multiple directions patient is to figure out what relieves symptoms and work from there. She was irritable on her R C2/C3 facet glide and I practiced my prone grade II PAs. I wanted to be ambitious but realized I had to take it easy. It’s interesting how she can complete cervical flexion/ ext/ SB/ rotation though a painful motion. My question was “where is she gaining this movement when she’s moderate/ severely hypomoble in her right C2/C3 and mod hypomoble C3/C4”? These are things that I’m trying to observe. I’m now not just checking cervical cardinal plan motions, but I’m looking at quadrants. I want to see her impairment and further isolate that motion. I gave her cervical binder exercises in supine so that she could learn how to control her neck without compensations of traps, levator, superficial muscles.
Further questions I ask myself:
How do I start making “maybe related” bold statements that draw a clearer picture? How do I continue to encourage movement through a hypomobile segment without further encouraging hypermobile segments? Why is a particular facet hypomoble and how do I further prevent that motion? How do I continue to build salience of exercises throughout the day without patients falling back into their habitual patterns?
I also agree with Laura about spontaneous movements. I try to see how a person first performs an exercises after a simple demonstrations, observe the movement and then provided the appropriate cue.