Evidence in Motion, LLC

1. Evidence in Motion, LLC Cervical Written Case February 1, 2013 Kahn Nirschl, PT, DPT, OCS EIM OMPT Fellow in Training

2. Rationale for choice of this case • Interesting case involving insidious cervical pain with a radicular component/referral pattern. • Patient has cardiovascular history that needed to be accounted for during the examination. • Interested to see how others would proceed when presented with a similar situation clinically.

3. Patient Information • 46y/o caucasian male; large endomomorph: 6’2” 325 pounds • Referred to PT by PCP • PMH: • Bilateral knee arthroscopies due to occupational injury; left knee 2/23/12; right knee 11/21/12 • Chief complaint: pain right cervical spine, anterior shouler/pec region and down right UE

4. Body Chart • P1/P2 share agg/all factors; P1: sharp pain; P2: radiating pain but without numbness • Aggravating factors • Right cervical rotation • Overhead reaching R UE • Alleviating factors • Rest/percocet P1 P2

5. Subjective • Patient reports insidious onset after sleeping on couch; reports “crick” in his neck; Due to medical history of cardiovascular problems, patient presented to ER and was cleared of MI; PCP referred with DX of cervical strain • PMHx: consists of HTN, elevated cholesterol • Red Flag: Denies 5D’s, 3N’s, and 1A • Yellow Flag: Cardiovascular risk factors, no elevated FABQ; history of occupational injuries • NDI score: 46%

6. SINSS • Severity: Moderate: not working secondary to current rehab for right knee arthroscopy due to occupational injury; functional ADLs but with pain with driving and use of right UE with lifting tasks overhead • Irritability: High: immediate onset of symptoms with movment of cervical spine that does not alleviate for several hours • Nature: Mechanical cervical painwith radicular component potentially • Stage: Acute • Stability: Worsening course

7. Objective • NPRS pain average for week= 7/10 • Cervical AROM: No nystagmus/vertigo • Flexion 25 Ext 15 • Left SB 20; Right SB 10 • Left rot 30; Right rot 70 • Shoulder ROM bilaterally WNLs comparable • MMT: No myotomal weakness • Hand dynamometer: 100lb right; 110 lb left

8. Objective • Sensory testing: C1-T1 bilaterally WNLS • Reflexes: 2+ • Hypomobile C0-1 craniocervical flexion grade II • Hypomobile C4-5 CPA, right UPA grade II • Hypomobile left 1st rib grade III • Increased muscle tonicity at right C4-5

9. Objective • Hypomobile UPA left T3-4 grade II • Cervical radiculopathy CPR: • + spurling, - ULTT A, + cervical rotation, - cervical distraction • + left CRLF • Shoulder cleared of referral by ROM with OP in all planes

10. Assessment • Symptoms appear mechanical in nature and acute, however insidious onset of symptoms, referral pattern and cardiovascular history gives me caution particularly since patient hurt bad enough to present to ER. Will treat manually focusing on thoracic spine first, progressing to cervical spine based on response while monitoring for any adverse change in symptoms.

11. Treatment (day 1) • Manual Therapy: • Prone T3 HVLA • Cavitation noted • Did not immediately re-assess asterisks • CPA continued at T2-10, as well as at left T3-4 based on tonicity and segmental hypomobility • Therapeutic Exercise: • Focus on immediate thoracic extension, and cervical retraction posturally to maintain any ROM gains noted following manual therapy provided. HEP with towel roll to self-mobilize thoracic kyphosis

12. Plan • If better: progress into cervical spine with CPA, UPA, manual stretching of cervical spine with further progression of exercise package for cervical stabilization and posture. • If same, re-assess asterisk signs and progress manual therapy package as appropriate including cervical spine if tolerated with consideration of manual cervical traction. • If worse, re-assess asterisk signs, and if same remain readjust intensity of exercise and manual therapy to reflect patient’s current status

13. Treatment (day 2) • After 1st session decrease in NPRS from 7 to 4 with decreased referral of symptoms to fingers to primarily the shoulder with intermittent symptoms in the elbow in a C5 distribution. • Addition of CPA/UPA of C3-5, MFR of cervical paraspinals, and upper trapezius. Continuation of HVLA at T3 and CPA T2-10 to decrease kyphosis. Progress seated thoracic extension and cervical retraction to supine DNF stabilization exercises as tolerated.

14. Treatment (day 3) • Continued pain decrease from 4 to 2/10. No referral of symptoms down right LE in any appreciable dermatomal pattern. • Progressed into HVLA at C3-4 supine, and the addition of resistance exercise in a position of thoracic extension, cervical retraction using scapular stabilizers and RC

15. Review of Case • What would I do differently: I didn’t re-assess between interventions manually frequently. Also I should have taken his vitals if I was concerned about any potential VBI or cardiac related diagnosis. Thinking about the case, it worked out well, but should I have gone to the neck sooner, maybe day 1. Overall, I feel that I responded to impairments that were present and proved my hypothesis vs. ruled out other pathologies.

16. Evidence in Motion, LLC Cervical Written Case 2/1/2013 Kahn Nirschl, PT, DPT, OCS EIM OMPT Fellow in Training