Evidence in Motion, LLC

1. Evidence in Motion, LLC Case Study Presentation: Cervical pain with C3-4 anterolisthesis April 3, 2013 Kahn Nirschl

2. Why this case? • Demonstrates successful use of a thoracic approach initially in the addressment of cervical pain, with an element of fear avoidance on the patient’s behalf in both behavior and thoughts on condition and what caused it. (exam occurred 3-13-13)

3. Chief complaint • Complaints of right sided cervical symptoms described as a deep ache most of the time at rest, and with a sharp stabbing pain in the right cervical spine with movements of the extremities overhead or with cervical extension. MOI was helping a friend with building an overhead structure on a house with sustained cervical extension looking up.

4. Reason for seeking treatment • Patient has had these symptoms in the past and is a chronic issue that has affected him over the course of the last 6 years. He had controlled it. He had MRI performed on 2-18-13 which reveals grade I 2mm anterolisthesis as well as severe bilateral neuroforaminal narrowing of C5-6 and C6-7. This MRI scared the patient hat he may have to have surgery. Wants to avoid it with PT.

5. Body Chart P1

6. Agg/Ease

7. 24 Hour Behavior

8. Subjective: Patient profile • 56 year old male business man who is in the construction business. His symptoms have kept him from physically working in his business for the last 2months. 2 item depression screen positive. One item FABQ question scored high at 5 out of a max score of 6 for activity avoidance in potential symptom aggravation.

9. Subjective: Current History • Onset: Chronic history with previous PT and chiropractic. He has real fear of manipulation of his cervical spine and feels this caused C3-4 anterolisthesis. Exacerbation 2months ago working on overhead structure on friend’s home. Pain was very high ranging from 8-9/10 at times and is described as debilitating. Last three weeks prior to PT exam, he had decreased symtpoms to 3/10 primarily with total rest and avoidance of aggravating activities.

10. Subjective: medical screening • Significant for HTN. • Medications significant for beta-blocker, lortab, flexeril • NDI=46% disability

11. Subjective: red/ yellow flags • Denies weight changes, severe night pain that does not change with rest or position change, fever, severe sudden onset of HA. • Positive depression screen, High score on one question FABQ question for avoidance of activities that cause pain, reports

12. SINSS

13. Initial hypotheses list • Cervical spondylosis/DJD • CT junction mechanical • T4 syndrome • Right levator/upper trapezius trigger point • T4 Syndrome • Somatic referral from right shoulder • Vascular/visceral referral

14. Thoughts following subjective exam • Initial impression of mechanical cervical dysfunction originating from lower cervical spine. • SINSS will allow for a complete, thorough exam but my vigor will be graded and in observance of limiting symptom provocation beyond what is necessary. • Objective exam will include Neurologic screen, AROM, PROM, PAVM of both the cervical and thoracic spine.

15. Objective exam • Observation • Forward head with left lateral sidebend in resting position with increased thoracic kyphosis • Shoulder cleared with functional movement testing with overpressure • PMHx and subjective exam did not reveal potential visceral referral and patient denies 5D’s, 3N’s, and A

16. Objective exam • Cervical ROM

17. Objective exam • Neuroscreen • Grip strength:left 86#, right 100# • Myotome: decreased right C5-6 myotome to 4/5 MMT; cervical DNF test of 10 seconds • DTR; • C5-6: left 2+, right 1+ • C6; left 2+, right 1+ • C7:left 2+, right 2+ • Neurodynamics:right median nerve tension but without P1 reproduction; decreased light touch sensation right C5-6

18. Objective exam • PAVM

19. Objective exam • PAVM

20. Objective exam • Testing: • + Spurling right • + Cervical disraction • + ULTT A right • + cervical rotation less than 60 degrees right and left (4/4 positive per Wainner et al cervical radiculopathy CPR) • + CRLF right • No trigger point that reproduced P1.

21. Hypothesis List Re-visited • Cervical spondylosis/DJD • CT junction mechanical • T4 syndrome • Right levator/upper trapezius trigger point • Somatic referral from right shoulder • Vascular/visceral referral

22. Subjective Asterisks • Ability to sleep without pain interruption throughout the night. • Overhead work with cervical extension x 60 minutes with pain to 7/10. • NDI=46% at exam

23. Objective Asterisks • P1 reproduction with UPA right C5-6 with pain report level. • Right myotomal strength C5-6 to 4/5 MMT. • Right ULTT A • Cervical ROM, particularly in extension, sidebending and rotation.

24. 1st intervention • Manual therapy • Prone HVLA T3 • Jt. Mobililzation C0-1 to increase cranio-cervical flexion • Cervical manual traction • MFR right levator, upper trapezius • Exercise: supine thoracic ext stretch with towel roll, supine chin tuck • Modalities: HP/Premod C2-T2 • Decrease in pain level from 3 to 1/10.

25. 2nd Intervention • Manual therapy • Supine HVLA T3 • Jt. Mobililzation C0-1 to increase cranio-cervical flexion • Cervical manual traction • MFR right levator, upper trapezius • Exercise: supine thoracic ext stretch with towel roll, supine chin tuck with DNF, barrel stretch for mid-scapular stretch, quadruped flexion/extension • Modalities: HP/Premod C2-T2 • Prior to treatment pain was at a 1/10, improved from visit 1

26. 3rd Intervention • Manual therapy • CPA T2-8, UPA right T3-4 • Jt. Mobililzation C0-1 to increase cranio-cervical flexion • Cervical manual traction • MFR right levator, upper trapezius • Exercise: supine thoracic ext stretch with towel roll, supine chin tuck with DNF, barrel stretch for mid-scapular stretch, quadruped flexion/extension, posture correct with RTB ER at shoulder, hor. Row, sh ext. • Modalities: HP/Premod C2-T2 • Prior to treatment pain was at a 1/10, improved from visit 1

27. 4thIntervention • Manual therapy • CPA T2-8, UPA right T3-4, CPA grade II-III C5-6 • Jt. Mobililzation C0-1 to increase cranio-cervical flexion • Cervical manual traction • MFR right levator, upper trapezius • Exercise: supine thoracic ext stretch with towel roll, supine chin tuck with DNF, barrel stretch for mid-scapular stretch, quadruped flexion/extension, posture correct with GTB ER at shoulder, hor. Row, sh ext. • Modalities: HP/Premod C2-T2 • Pain levels remain at 1/10 with decreased neural tension in median nerve

28. Discharge Planning • Increase segmental mobility of C5-6 and T3-4 increasing overall cervical ROM. • Increase DNF strength greater than that of 10 seconds at exam. • Educate about appropriate ways to work that will limit cervical extension. Thoughts on the case: I saw this as an opportunity of a multi-modal approach and took into account the patient’s fears of his cervical spine into treatment by beginning with the cervical spine. The cervical radiculation CPR was positive but I felt that traction alone would not be sufficient for him but it was used as well.