Evidence in Motion, LLC

1. Evidence in Motion, LLC Case Study Presentation: By Mark Milligan, Fellow-in-training November 6, 2012

2. Why this case? • Primary complaint was difficulty swallowing • And so was the referral • Limited evidence • Sinister pathology suspected

3. PATIENT PROFILE Chief complaint: Patient complained of “Sensation that there is something in throat when swallowing.” She said the front of her throat feels tight. The sensation was of insidious nature. Swallowing not the same since her surgery to remove a malignant tumor at the top of her stomach 6 years prior. Patient Profile:65 year old retired female. She is tall and thin. She is very rushed and wants the quickest answer that I can give her. She seemed very informed about her condition, medical terminology and possible interventions.

4. PATIENT PROFILE Date of onset: 6 months ago Self Reported Scores / Outcome Tools: FOTO score = 66 with 2 point change in 12 visits Fear - Low

5. BODY DIAGRAM • Primary complaint (s): • P1: She reports that it is difficult to swallow, like there was something in her throat. She reports never choking or things going down the wrong tube. P1

6. PATIENT INTAKE • Medical History / Co-Morbidities / Review of Symptoms (ROS): • Red Flag Screen: History of stomach cancer 6 years ago, had similar feeling then as well. • Yellow Flag Screen: High Cholesterol • Special Questions: She answered no to the depression questions on medical history. • Medications: Nexium (Current condition), Pravastatin (Cholesterol)

7. PE Planning I. What areas/structures must be considered a source of symptoms?

8. Early Hypotheses – Pre Interview

9. HISTORY • Current Episode: She reports that her current episode of difficulty swallowing began about 6 months ago about 5 1/2 years after she had surgery to remove a large tumor from the top of her stomach and lower esophagus. The onset of this sensation had a gradual onset over 3 weeks and stayed the same for 5 months. It had gotten progressively worse over the 3 weeks prior to her evaluation but has seemed to plateau over the last week. • Previous Episode: She had a similar episode of difficulty swallowing before they found the stomach tumor (6 years ago) but she reports that had to do with reflux she was dealing with because of the size and location of the tumor. She reports that her current sensation is similar but definitely different.

10. Symptom Behavior Area of Symptoms Aggravating Factor Easing Factor

11. 24 Hour Period

12. Subjective Exam Red flag questions: History of cancer was followed and treated. No pain at night or symptoms, no weight loss, no loss of fine motor skills in hands, no difficulty walking, no HBP, no facial numbness or droopiness, no searing headaches, no slurring of speech, no memory loss, no history of trauma. Question: Have you followed up with your current care providers especially your ENT and oncologist? She reported that she has followed up with everybody. She has had a recent throat/upper abdomen MRI (4 weeks ago), a PET scan (2 weeks), and an endoscopy last week. She has also had countless CBC’s looking for infection or other signs of metabolic activity. She has been “worked over” and not in a good way. Question: Could you take me through your recent experience with cancer including surgeries, chemo therapies, and radiation? She was diagnosed with a large malignant tumor near the apex of her stomach. She had first had difficulty swallowing and she was throwing up. PCP thought something was off and had some tests run and they found the tumor. She had surgery within 3 days. She said they opened her all the way up and even cut her sternum in half. She reported her ribs being pulled up and out of the way. They were able to get all of the tumor. She did not have any chemotherapy or radiation.

13. Subjective Exam Question: Do you ever choke on food or liquids? No, I don’t have difficulty swallowing, I just feel like I can’t. Question: So the feeling is more like you can’t get things to go down? Exactly, I feel like there is just something is in my throat. Not necessarily the food. Question: Do you have pain any where? I have no pain any where. In fact I feel great having had my bout with cancer. Question: When did you start taking your statin meds? About 8 months ago, my PCP prescribed them to me. Question: Anything else that I need to know? I don’t really know why I am here. I don’t think that physical therapy can help me.

14. Subjective Asterisks • What will you use as your asterisk signs from the history? • P1 : Difficulty swallowing: Time to onset after getting up. 10 min. • P1 : Difficulty swallowing: Intensity at the end of the day. 8/10.

15. Hypotheses • What initial hypotheses have you ruled out during history? • Cancer, stroke • List your primary and secondary hypotheses in prioritized order for P1: • Upper motor neuron lesion • Upper cervical ligamentous instability • Anterior cervical muscle imbalance • Cervical referral • Medication side effect • S/C dysfunction

16. Hypotheses – Pre Exam

17. Clinical Reasoning

18. Clinical Reasoning

19. Clinical Reasoning What is your concept of the patient as a person and how will this affect your examination and subsequent management ? • The patient is friendly however she does not think that her current situation can be helped by physical therapy. I will need to make sure that I communicate to her my findings but also recreate or alleviate her symptoms during the exam to get patient buy in. I think that if I can make a change in her symptoms then she will feel more confident that I can help her.

20. EBP triadProblem 1 • Best available evidence: Most of the muscles of swallowing are innervated by cranial nerves. Based on her surgical type and history, the fact that she has been cleared by all of her providers, and the fact that she can push on a spot and alleviate her symptoms make she a candidate for PT. If not able to reproduce or change sx, increases side-effect of meds. • Patient preferences: The patient is giving PT a try because of her MD’s request. She is not convinced that PT will help. • Clinical experience: I have never treated anyone for difficulty swallowing in the outpatient setting. I have treated many patients with muscle imbalances. I need more information from the physical exam to determine if she is appropriate fro PT.

21. Planning OE • I need to approach her physical exam with the mindset of clearing her to be in PT. I need to perform full neuro screen, upper cervical ligamentous testing, and cranial nerve testing, also: • Palpation • Cervical active ROM • Observe her swallowing • Passive cervical motion • S/C joint assessment

22. Planning OE • Observe • Breathing- Chest/belly breathing • Sitting posture- Forward head/rounded shoulders • Functional Tests • Swallowing • Cranial nerve exam • Sharp-Purser • Cervical AROM • Overpressure / repeated if needed to reproduce symptoms • Quadrant testing if needed • Neurological Exam – would expect normal • MMT UE – would expect normal

23. Planning OE • Supine • Palpation • Alar/transverse ligament testing • UNLTT’s • Cervical PROM • Distraction test • S/C joint assessment • Prone • PAIVM – C-spine and T-spineto assess for mobility and pain

24. Physical Exam • Functional Tests • Breathing: Belly breather with no upper chest excursion. • Swallowing: Seemed labored. Looked like she was trying to swallow something very sticky. • Observation • Slight forward head and rounded shoulders • Decreased cervical lordosis • Flat thoracic spine

25. Physical Exam • Cervical AROM- Full and pain free and cleared with O/P • Sharp-Purser- No change in sx, reductive thunk nor movement • Cranial Nerve Screen- ALL Negative, particularly VII (Facial taste), IX (Glossopharyngeal), X (Vagus), XII (Hypoglossal)

26. Physical Exam • DTR – 2+ for all and NEG: Hoffman’s, Babinski, Clonus • MMT – All strong and pain free and normal sensation • Alar/Transverse Ligament testing- Negative • UNLTT A – no reproduction of any sx • Palpation- Sub-occipital musculature was tender. Was able to alleviate symptoms with pressure to L mastoid at SCM attachment. • SCM, Scalenesboth painful with wincing, hypertrophied • PIVM – Normalmotion, hypomobile of lower and upper C-spine but pain free. • Distraction test - Negative

27. Physical Exam • OA/AA – AA restricted to the L but not painful • S/C joint assessent– Large, hypomobile, and painful with PA’s. Her swallowing difficulty was alleviated while I performed a PA of S/C joint • Craniocervical Flexion Test – Could not hold 24 mmHG for 10 second hold • Prone Cervical PA’s and UPA’s – All pain free

28. Clinical Reasoning • Is this a typical pattern that I have seen before? • No, I have never seen a pattern of a joint/muscle affecting swallowing before. • (-) Upper motor neuron testing, Cranial nerve screen, Upper cervical ligamentous testing, cervical radiculopathy, • I was able to change her P1 with 2 different manual techniques. • Have I cleared possible meds as a possible cause? No- If she does not respond to treatment she needs to be referred back to PCP. • Have I reached a treatment threshold? I was able to change her P1 and found multiple ways to do so. I reached a treatment threshold. I usually give a patient 2-4 weeks to respond to conservative management. I think that it is appropriate to be on the shorter side with this patient based on her medical history.

29. Assessment & Plan • Diagnosis – S/C joint dysfunction and anterior cervical muscle imbalance. • List your historical and physical exam ‘asterisk’ items: • Time to onset of sensation < 10 minutes • Subjective sensation during swallowing 4 -8/10 depending on the day • Craniocervical Flexion Test Time 24 mmHG for 10 secs • Plan – Good prognosis if she responds to treatment • Pt education on what PT can do, deep neck flexor strengthening, posture, stretching.

30. Day 1 Treatment Treatment provided today and the patient’s response to each intervention.   TREATMENTS Supine – PA’s to S/C joint. Supine – Subocciptial release with focus on L SCM attachement. Education and HEP Teach deep neck flexor and how to palpate for firing of SCM SCM, Scalene stretch RESPONSES TO… Decreased P1 in sitting from 6/10 to 3/10 Decreased P1 in sitting from 3/10 to 2/10 Very difficult to perform DNF without SCM’s firing

31. Response & Assessment at Day 1 HEP: Teach deep neck flexor and how to palpate for firing of SCM Anterior neck stretching. Plan for the next session: • Expectation: Decreased frequency and intensity of P1 • Better: Continue with manual, assess scapular strength and introduce exercises, add DNF with bio feedback. Add A/A MET, STM to SCM, scalenes. • Unchanged: Add soft tissue to other anterior musculature, A/A MET. Repeat day 1 treatmentwith higher intensity. Assess HEP techniques. • Worse: Review response to treatment. Increase intensity of manual treatment.

32. Asterisk Signs (Pre):She had longer onset to P1 in the morning. By day 3 onset is 2 hours after getting up. Her current maximum P1 was 5/10 Subjective:Patient reports being surprised by her response to PT and was happy. Objective: Palpation of L SCM and sub occipital musculature was tender and continued to decrease P1. S/C joint still painful and stiff but also decreased P1. A/A restricted to L. Low trap 3/5 (mild tipping missed on initial exam), mid trap 4/5, serratus 4/5, pec minor length sort (post acromion 2.5 inches from table bilaterally) Second Visit

33. Second Visit • I see her for her third visit on Wednesday and will update before presentation if I can! TREATMENTS Continued treatment Day 1 plus: SCM and scalene manual stretch and STM A/A MET technique DNF with bio feedback Scap stabilizer and strengthening (Lower trap, mid trap, serratus) Pec stretching RESPONSES TO… Decreased P1 in sitting to 4/10 Decreased P1 in sitting to 2/10 A/A: No change in P1, just felt good No increase or change in sx with exercise

34. Questions?