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Monthly CASE PRESENTATION

Monthly CASE PRESENTATION. Ron Masri, PT, Doctor of Physical Therapy Board Certified Orthopedic Specialist Certified Athletic Trainer Fellow In Training, Evidence In Motion BODY REGION: Cervicothoracic , Upper Extremity. PATIENT INTERVIEW.

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Monthly CASE PRESENTATION

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  1. Monthly CASE PRESENTATION Ron Masri, PT, Doctor of Physical Therapy Board Certified Orthopedic Specialist Certified Athletic Trainer Fellow In Training, Evidence In Motion BODY REGION: Cervicothoracic, Upper Extremity

  2. PATIENT INTERVIEW • Patient Profile: Pt is 31 yr old female, referred by an ortho PA-C for constant neck pain that radiates down into R shlder down her lateral arm to her elbow. She rated her pain between 7-9/10. She also describes an intermittent sharp shooting pain from her R neck up into the base of her skull with occasional ear popping sensation. She described her arm pain as a throbbing pain. She does experience the felling of occasional weakness R UE with gripping—but had not dropped anything. Her pain began in early Jan & not associated with any specific injury. Had x-rays that was negative for any bone pathology. Previous treatment of rest and steroids did not help. She stated that over the next few mths her ROM improved but then started noticing the arm pain and shooting pain into her skull on the R side that which sparked referral to PT. Pt is avid runner and wants to get back to running / working out/ and being able to sit with ease with out any neck or R UE pain • Self Report Outcomes: FOTO score Head, Neck, Thoracic Outcome: 34%, NDI-18/50 (36%) Chief complaints: P1 –R Unilateral neck pain P2-R shlder/ arm pain with feelings of weakness

  3. PATIENT INTERVIEW P1: Constant, Sharp shooting Agg: Sitting at computer, driving, looking over her shlders increase s her pain Rel: laying down. Pain meds Pain: 6-10/10 P1 P2 Patient believes P1 Related to P2 because P1 leads to P2 She cannot have P2 w/o having P1 P2. Constant; throbbing Agg:sitting, UE activity Rel: arm resting on console when driving; laying down

  4. Early Hypotheses – Post Body Chart • List your primary and secondary hypotheses in prioritized order: • P1 • Cervical Radiculopathy • Cervical Facet Dysfunction • Myofascial pain • P2 • Cervical Radiculopathy C5 • Shoulder Impingement/ RTC tear • Upper thoracic spine/ rib dysfunction • Lung visceral referral

  5. Symptom Behavior • Primary complaint in depth: • P1: R unilateral neck pain that at times can be sharp and shooting up into the base of her skull that can last a few hrs w/ occasional ear popping sensation • Secondary complaints • P2: R shoulder pain with radiation to the elbow (anterolateral) • Numbness and or Tingling: denies but does c/o of “weakness feeling” in hand • Relationship between symptom areas: • P1 gradual onset in Jan • P2 began a few months after cannot have P2 with out having P1 first

  6. Symptom Behavior • Activity and Participation Capabilities and Restrictions: • Activity restrictions & Aggravating/Relieveing Factors: • P1 aggravated with sitting/ driving > 30 min. Does worsen as day progresses depending on activity like sitting at a computer. Turning head to either side quickly causes the shooting pain from neck up to base of her skull—makes it difficult to drive to see blind spot • P2 worse when P1 is really hurting; then any head and arm motions increase R lateral arm pain; when flared up can hardly move her R UE due to feelings of weakness and throbbing pain. Has to go lay down to ease things and that takes about 10-15min • Sleep and 24 hour pattern: • Denies night pain • Stiff in AM in her neck R >L, no arm pain in AM • P1-2 get worse through out the day esp if having to spend time at computer doing the books (she is manager at Panera Bread) –sits a lot at computer

  7. PATIENT INTERVIEW • Medical History / Co-Morbidities / Review of Symptoms (ROS): • Musculoskeletal Hx: • History of LBP, L peronealbrevis repair Aug 2011 • Red Flag Screen: NONE • Yellow Flag Screen: NONE • BP 118/64 HR 70

  8. Clinical Reasoning Component • (S) What is the severity of the condition (min, mod, severe)? • P1= Moderate, worst pain 9-10/10, has not attemptedrecreational/vocational activity due to possibly exacerbating her symptoms, no difficulty sleeping • P2= Moderate, worst pain 7/10, has not attemptedrecreational/vocational activity, no difficulty sleeping • (I) What is the irritability of the condition (min, mod, severe)? • P1= Min-Mod, takes 30 min for provoke sleeping not effected, pt still working • P2=Min-Mod, takes >30 min for provoke, sleeping not effected, pt still working • (N) What is your primary nature statement of the problem (hypothesis). • P1= Cervical facet dysfunction • P2= Referred pain C5 radiculitis

  9. Clinical Reasoning Component • (S) What is the stage of the disorder for its current episode: • P1-started in Jan pt referred to PT end of march -- Chronic • P2 started 3 weeks prior -(sub acute) • (S) What is the current stability of the disorder: • Stable—but getting worse due to R UE pain • ** Discuss how the results of the SINSS will lead to planning the exam: • Pt is appropriate for PT • Will try to reproduce pain with OP per pt response

  10. Clinical Reasoning Component • What will you use as your asterisk signs from the history? (Specify for P1, P2, etc) • P1 Cervical active range of motion, sitting/driving >30 • P1 provokes P2 • List your primary hypotheses in prioritized order: • P1= C5 facet dysfunction, Myofascial Strain, Cervical Radiculopathy • P2= C5 radiculitis, Shlder impingement

  11. Clinical Reasoning Component • List your hypotheses and items you must rule out for each P: • P1 • Cervical radiculopathy= ROM,joint mobility testing • Cervical dysfunction= ROM, joint mobility testing • Myfascial Strain=length tension testing UT/Levator, palpation ,ROM • P2 • cervical radiculopathy= ULNTT, joint mobility testing, distraction • Upper thoracic/rib dysfunction= joint mobility testing, CRLF • shoulder impingement –ScapDyskinesis, Scap assist/Reposition tests, Hawkins-Kennedy, Neers, MMT, ROM (painful arc)

  12. Clinical Reasoning Component • List issues that you feel may predispose or contribute to the main problem: • NO yellow/red flags • List the non-musculoskeletal issues that you have ruled out in your history: • Cervical Myelopathy?? (needs to be on the radar)

  13. Planning the PE • What will you include in your physical exam to rule in/out your top hypotheses? • Cervical Facet Dysfunction= range of motion, joint mobility testing, Cervical Quadrant • Cervical Radiculopathy-distraction, Compression, ROM, Spurlings, ULNTT, Neuro Exam • Myofascial Strain=ROM, palpation, muscle length • Shlder impingement= ROM, MMT, special test (Hawkins) • Treatment strategy (relate to hypotheses and SINNS) • P1= joint mobilization, Cervicoscapular strengthening, posture training, ergonomic evaluation • P2= Scap stabilization training, posture training, total arm str

  14. Planning the PE • What areas/structures must be considered as a possible source(s) of the patient’s symptoms? • Joints: Lower Cervical Spine, 1st or 2nd rib, AC joint, GH joint • Muscle/Tendon: Upper trapezius, levator scapulae, deltoid, RTC, biceps • Other: Neural C5-6, lung • What will you assess Day 1, Day 2, Day 3 (prioritize), and why? • Day 1 • Phase 1 Diff Dx, clear shoulder, cervical spine • Day 2 • Thoracic

  15. Planning the PE • What areas/structures must be considered as a possible source(s) of the patient’s symptoms? • Joints: Lower Cervical Spine, 1st or 2nd rib, AC joint, GH joint • Muscle/Tendon: Upper trapezius, levator scapulae, deltoid, RTC, biceps • Other: Neural C5-6, lung • What will you assess Day 1, Day 2, Day 3 (prioritize), and why? • Day 1 clear shoulder, cervical spine; Mechanical vs Inflammatory • Day 2 • Thoracic (regional Interdependence)/ Scapula • Myofascial Cervical Muscles

  16. Physical Exam Precautions and Contraindications: NONE Postural Observation: Moderate forward head Functional movement analysis (* sign):* Apleys scratch test full and equal Bilaterally—no pain R UE Cervical AROM: Cervical flexion 2 fingers to manubrium, Extension 40 deg pain R side neck; R Cervical Rotation pain at end range, OP increased R side neck pain no increase in arm pain, L Cervical ROM reported stiff/ tight R side of neck when asked pt to place R UE on shlder and repeat L cervical ROM no c/o tightness Unable to reproduce arm pain with typical cervical ROM

  17. Physical Exam • Neurological Screen • Sensation: Intact to light touch/ sharp dull R UE • DTR’s: C5, C6, C7 normal Bilaterally • Motor: Gross weakenss 4/5 --Bilaterally UE with pt requiring a shlder shrug & slight chin poke for stability • Upper Motor: +neg Hoffman

  18. Physical Exam Shoulder Screen: Full ROM all planes Overpressure does not reproduce symptoms (-) Hawkins-Kennedy Slight winging of the scapula-type 1 scap (inferior pole sticks out) Slight scapular dumping on the R with decent Cervical Testing: Neg on Cervical Rad cluster; distraction and Compression both alleviated R arm symptoms Cervical Quadrant R reproduced R UE discomfort to mid lateral arm Alar/ transverse negative R ULTT median: (+)with reproduction of symptoms with just 50 deg ER component Accessory motion: CPA’s C3-5 hypomobile-stiff no reproduction of symptoms R UPA C2-3 reproduces P1 R UPA C4-6 reproduced P2

  19. Assessment, Plan & Treatment • (N) What is your primary nature statement of the problem (hypothesis) following the PE findings as well as the competing hypothesis: • P1 Cervical Facet Dysfunction at C2 • P2=C5 facet dysfunction leading to C5 radiculitis • List your historical and physical exam ‘asterisk’ items: • Hx: sitting/ driving >30 min, turning head quickly • PE: Cervical ROM Extension, R Rotation, Cervical Quadrant R • Prognosis (note timeframe of expected level of recovery): • She will do great 6-8 visits • Precautions or Contraindications to treatment: NONE

  20. Treatment Day 1 : Treated R UPA’s at C2-C3-C4 30 sec x 3; reassessed Cervical ROM –no pain with Rotation end Range R (goniometer); still had + R cervical Quadrant around base of neck on that side Treated C5/C6 UPA’s on the R 30 sec x 3, R cervical Quadrant negative; Cervical extension improved to 60 deg with buble inclinometer; R ULTT median improved to 70 deg from full extension HEP Cervical ROM 2 finger on manubrium; Chin tucks; Robbery emphscap depression & retraction—did 15-25 reps every 2-4 hrs Rationale For Treatment: Pt did not fit mobility category of neck

  21. ASSESSMENT-Day 2Day after IE Subj: denied any R arm pain; pain now just localized R neck region Obj: + cervical Quadrant R but this time Reproduces pain down into R shlder blade and not arm Cervical ROM full all planes still c/o tightness due to tissue restriction with Rotation Tight UT/ levator/ pecs—but nothing reproduced her R neck pain Weak DNF—likes to drive with chin with Neck lift off test Accessory testing: Centrally she was fine UPA’s R C2-3-C4 stiff before pain that was localized UPA’s C5-C6 stiff but no R UE pain R Median ULTT + 90 deg ER component for R arm pain to elbow

  22. Treatment-Day 2Day after IE R UPA’s C2-4 45 sec x 5—stiffness and pain improved significantly as progressed with technique; Cervical Quadrant improved stiff now with no pain in scapula on the R; no change ULTT median Lateral glides L C4-C6 with pt in the Upper Limb Neurodynamicsposition 30 sec x 3 at each segment; reassessed ULTT R median improved to 30 deg from full elbow extension DNF training emph CCF with stabilizer/ posture/ ADL modification

  23. ASSESSMENT-Day 35 Days after IE Subj:No arm pain, feels 80% better, can turn head quickly while driving with sharp pain Obj: - cervical Quadrant R; Cervical ROM full all planes No issues with R Median ULTT Treatment: Addressed Soft tissue restrictions in UT/Levator/ pecs; continued with DNF training and initiated scapulothroacic stabilization emph SA/lower traps

  24. Final NOTES Pt was seen for 2 additional visit 2 weeks apart and continued to report no neck or arm pain Over those two visit we got her going on more functional ex’s emphasis Cervical and Scapular stability with functional task training that involved pushing/ pulling/ lifting and carrying—her HEP emph scapular stabilization program; we also did some ergonomics training too At her last visit—min to no scapular dyskinesis noted—she said she is able to work at a computer and drive as long as she wants too—but limits it to no more than 2hrs—she remained compliant with HEP

  25. Final NOTES After placing the patient in the Mobility category, I transitioned her to the Endurance and Strengthening classification --- After having all this talk about T-spine manipulation addressing the neck pain—I did not have to go there with this patient as she did fine with cervical mobilization---I don’t think she fit the prelim CPR for cervical manipulation so that too was not necessary

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