Evidence in Motion, LLC

1. Evidence in Motion, LLC FVR Live Case #3 Matt Anderson June 12, 2013

2. Patient Profile • 46 y/o caucasian female • Works as a psychologist, seeing patients who have PTSD and TBI from combat • Has a 21 year old son • Enjoys yoga, kayaking, and hiking

3. Chief Complaint • Chronic R>L neck pain- described as muscle pain extending from the occiput along the spine of the scapula, with insidious onset in 1998; currently L side minimal complaint • Intermittent numbness/tingling: R lateral neck extending down the arm to the fingers (pt had a difficult time describing exactly where the numbness occurred and I did a poor job of clarifying) • Tension type headaches, along with migraine headaches (some variation occurs daily) • Various locations: suboccipital region, temporal region, supra-orbital region

4. Reason for Seeking Treatment • To improve ability to concentrate • To reduce tension type headache frequency and duration • To improve tolerance of yoga and kayaking • Has had several bouts of PT, with some improvement. Improvement with chiropractic manipulation and acupuncture, as well.

5. Patient Self-Report Measure FOTO: 30/33 (1st visit) Central Sensitization Inventory (visit 2) -Appendix A: 71/100 -Appendix B: Fibromyalgia, TMJ disorder, Migraine/tension type headaches, Neck injury, anxiety- 5/10 present

6. Body Chart Sharp, Migraine Tightness, Achhiness Dull pain Variable numbness

7. Aggravating factors • R rotation of the neck • Painting (1 stroke does not bother her, repetitive brush strokes with RUE produces achiness in upper trap mid-belly extending to the occiput) • Times of increased stress correlate with increases in headache frequency • Prolonged sitting posture at work • ***I did a poor job of asking clarifying questions at this session- 2nd visit I tried to remedy this

8. Alleviating factors • Yoga rotation poses • For the cervical pain- L rotation • For migraines: turning the lights down low, reducing noise around her, medication • For tension type headaches: pressure placed on the mid-belly trap slightly relieves symptoms

9. 24 hour behavior

10. Current history • The patient reports an insidious onset of R neck/scapular pain in 1998, with variable R side headache. She reports that the origin of the headache pain begins at the middle/ superior scapula, travels up the right neck and into the temporal area. She reports a long history of migraine type headache, with light and sound sensitivity, but no specific aura.

11. Past History/Medical Screening/ Red/yellow flags • PMH: • Fibromyalgia, h/o tempormandibular joint disorder, migraine and tension type headaches, h/o neck pain, h/o anxiety, h/o R ankle fracture, + h/o low back pain; report of C5 and C6 disc herniations from MRI • Red flag screen: no bowel/bladder changes, no weight gain/loss, no unsteadiness of gait, no h/o cancer, no h/o surgery, no h/o double vision, no h/o MVC • Yellow flag screen: 2 part depression screen questionnaire: negative; I did not give her a FABQ

12. SINSS

13. Initial Hypothesis List • 1. Cervical radiculopathy • Location of symptoms, posture, numbness • 2. Facet joint rererral • -Location of symptoms (C6/7, C5/6, C4/5, C3/4, C2/3) • 3. C0/C1 referral pain • 4. Muscle referral pain- upper trapezius, SCM, semispinaliscervicis

14. Initial Impression • The patient has chronic pain located at the R neck, upper trap, and central scapula. Intermittent numbness present in the RUE. Variable headache symptoms- seem to be related to stress, light, and posture. She has good expectations for physical therapy. Prior to the 1st visit, she mentioned that she thinks that manual therapy, posture/breathing exercises, and dry needling will be beneficial.

15. Objective Exam • Observation: R shoulder elevation in sitting • DTR: R side only- WNL; will check L side at subsequent visit • Sensation testing: C6, C7, C8 WNL- need to perform again because I performed over her shirt

16. Objective Exam • Cervical ROM: • Flexion- 55 degrees, felt at lower c-spine • Extension- 70 degrees- no familiar symptoms; dizziness produced • Rotation- L WNL (will check OP at 2nd visit)

17. Objective • Supine position: • Distraction: increased tension at suboccipital region • PPIVM: • 0/1, C1/C2: limitation in flexion • Stiffness at end range flexion at C4, C5, C6 • Tenderness/ tightness/ muscle guarding at suboccipital region with palpation • Upper cervical flexion- difficulty holding position, SCM- difficult to inhibit to reduce upper cervical extension

18. Treatment • Manual treatment: • Soft tissue mobilization of suboccipital region • Soft tissue mobilization of mid-belly upper trap • Therex Chin tucks • Taught with manual cues • Also utilize this exercise if/when the tension type headache develops

19. Exam and Initial Treatment Reflections • I missed a great deal during the subjective exam. I did a poor job clarifying aggravating and easing factors, as well as, the pattern of referral. I had less time than I usually have, and I felt like I needed to have some treatment during the session. The cervical retraction exercise reduced her pain from 4/10 to 2/10, and that was all I had time for. She had reported that acupuncture had a positive impact. She had positive expectations for trigger point dry needling. I talked the case over with my mentor, and he gave me some recommendations.

20. Prognosis • Fair to good prognosis. She has had treatment from a variety of disciplines with variable outcomes. Her FOTO score showed that only more vigorous activities were limited a little. She has positive expectations for physical therapy, and would like to progress her activity level (greater frequency of yoga and kayaking).

21. Plan for 2nd Visit • Give patient Central Sensitization Inventory • Assess cervical flexion rotation • Dermatome assessment • Myotome assessment • Palpation of SCM

22. 2nd Visit • Pt reported that over the past week she has had 2 migraines (1 was intense enough that she had to leave work) • On 3/5 of the other days, she was able to keep her tension headache to 2-3/10 using the chin tuck exercise • Case was discussed with mentor and he recommended using the CSI: Central Sensitization Inventory -Appendix A: 71/100 -Appendix B: Fibromyalgia, TMJ disorder, Migraine/tension type headaches, Neck injury, anxiety- 5/10 present

23. 2nd Visit Clarification for SINSS: -Severity: Vocational activities: can be limited after ~3 hours of sitting in chair: concentration, slow down her typing speed; pain at mid belly UT to base of occiput to6 /10; Avocational activities: style of yoga chosen dependent on daily symptoms- examples: breathing/relaxation vs focus on rotations vs focus on flowing poses (the past week: no yoga on migraine days, 3 days of relaxation /breathing, 2 days of rotation poses); kayaking tolerated for 1 hour on flat water- this increases her R neck symptoms to 6/10 with headache which wraps around the R ear to the temporal area -Irritability: ~ 3 hours of sitting at work produces an increase in headache from 4/10 baseline to 6/10---at ~ the same time frame the thumb/finger symptoms begin to increase- 15 minute standing break brings headache and arm symptoms back to baseline (cumulative increase in headache pain and reduction in ability to concentrate as day progresses); Breathing/ relaxation yoga can bring h/a symptoms to 3-4/10 from 5-7/10; If the tension type h/a gets to 7-8 level, a migraine is usually triggered, and this will keep her from work for at least 1 day, but up to 2 days -Nature: Thumb, index and middle finger are areas of numbness- C6/C7 involvement; Cervical flexion rotation test: ~50% restriction to the right;

24. 2nd Visit • L cervical rotation full- no pain with OP • R cervical rotation: 55 degrees with pain at end of this range at 5/10, after 10 reps pain increased to 6/10 • Dermatome assessment: All dermatomes re-assessed- no report of differences • Myotome assessment: C4-T1 symmetrical • Palpation: SCM –R proximal pincer palpation produced familiar frontal pain;

25. 2nd Visit -Manual Therapy: -Supine Upper cervical distraction mobilization -4 x 30 seconds - Less muscle stiffness/guarding during manual and active chin tuck motion -Trigger point dry needling -Upper third of SCM -Familiar frontal pain produced Therex: -self OA distraction with upper cervical flexion -Scapular retractions

26. 3rd Visit • Pt reports 1 migraine 4 days after 2nd session- had to leave work at lunchtime • Other days she was able to keep her pain at 3/10 level using seated and/or supine chin tucks and scapular retractions • Finger numbness present at moderate level today (thumb, index and middle fingers)

27. 3rd Visit • Manual Therapy: • C6 and C7 UPA grade III • 4 x 45 seconds • Initially produced increase in thumb numbness • Numbness abolished after 4 rounds • Supine upper cervical distraction mobilization • Reduction in muscle stiffness/guarding observed after 5 rounds of ~1:00 • Cervical flexion rotation test symmetrical • Therex: • Supine self upper cervical distraction mobilization- added to chin tuck -Rotation to R 65 degrees with pain 2/10

28. Reflection following 2nd and 3rd visits • I did a poor job at the first visit of gathering the needed information for me to make good decisions. At the 2nd and 3rd visits, I was able to clarify some points. The patient reported that she has improved concentration during the morning- she can now complete all of her paperwork prior to going to lunch. Prior to these sessions, she had leftover paperwork at the end of the day. The afternoon continued to be difficult for concentration- I think I need to begin to add more of an endurance component to her care. I need to improve my assessment and treatment of the upper cervical spine, in relation to headaches.

29. Discharge • I ended up seeing this patient for a total of 8 visits over 6 weeks • At the last session, the patient had the following improvements: • Full R neck ROM, pain free • Improvement in ability to concentrate at work for ~5 hours, mild loss of concentration after this time • Able to tolerate daily yoga sessions (type still varied with symptoms) • Able to kayak 2-3 times per week on flat water, with variable, slight headache or neck symptoms • She continued to have migraines at the frequency of 1-2 times per week

30. Anderson Case • Thank you for your questions, comments and suggestions.