Evidence in Motion, LLC

1. Evidence in Motion, LLC FVR Live Case #2 Matt Anderson Enter Date

2. Why case was chosen? • I learned from my first case that I need work on the recognition of common clinical syndromes. This case appeared to be very similar to my first case. Subha’s recent case also helped me to start to be more streamlined in my thought processes.

3. Chief Complaint • Low grade, constant, L lateral UE, forearm and thumb/index finger numbness; achiness in lateral L arm and into lateral forearm

4. Reason for Seeking Treatment • “My arm goes to sleep sometimes really bad” • “My arm gets achy after driving, and after working in my yard, from the front of the shoulder to my thumb.” • “ My numbness increases when I watch TV or drive”

5. Patient Self-Report Measure • NDI: 9/50 • quickDASH: 18/55

6. Body Chart achy Achy ✓ ✓ ✓ numbness ✓

7. Aggravating factors • Sleeping on R side (increase from minimal to moderate tingling in hand) • Arm position: Shoulder neutral, full elbow flexion and wrist extension- occurs when driving and watching TV (increased numbness to moderate after 10-12 minutes; severe after >30 minutes

8. Aggravating factors • Putting jacket on- immediate increase in numbness to moderate while reaching L arm into extensionto get jacket on • Raking leaves produces increase in achiness from 3/10 to 6/10 during the activity

9. Alleviating factors • Get out of positions described in aggravating factors • Moderate to severe numbness when he wakes up (in morning)- ~20 minutes of movement reduces to trace • Once he gets the jacket on, takes ~5 minutes to return to mild numbness • When the raking stops- takes ~5 minutes to return to baseline with just rest

10. 24 hour behavior

11. Patient profile • Retired 65 y/o AAM; worked various jobs-heavy manual labor. • Main hobbies/ interests include fishing, yard work, spending time with his wife • Positive attitude, and very high expectations for physical therapy

12. Current history • Patient reports insidious onset of L lateral arm achiness when he woke one morning in mid-December. He thought that he had just pulled a muscle. The ache progressed to his hand by late January. Numbness started in late January. Symptoms have stayed the same since this time.

13. Past History/Medical Screening • PMH: • Anemia, h/o atypical chest pain, h/o hepatocellular carcinoma, cirrhosis, colonic polyps, erectile dysfunction, HTN, neuropathy, h/o seizures (surgery mid-2012) • System clearing: • Recent f/u echo: negative • Recent oncology visit: in remission • Reports abstinence from alcohol • Neuropathy in feet- treated with anodyne • Seizures- controlled w/ medication

14. Red/Yellow Flags • No bowel/bladder changes • No gait abnormality • h/o atypical chest pain • Neuropathy present (reports only LE’s) • Questionable continued ETOH abuse • Pt reports h/o seizure activity, headaches and dizziness, with surgery, and is currently controlled with medication • Depression questionnaire: Negative

15. SINSS

16. Initial Hypothesis List • 1. Cervical radiculopathy • Location of symptoms, posture, numbness, symptoms change after prolonged position • 2. C6 involvement • Location of symptoms • 3. Radial nerve involvement • Location of symptoms • 4. Thoracic outlet syndrome • Location of symptoms • 5. Referred from shoulder • 6. Muscular referral- scalenes, infraspinatus

17. Initial Impression • The patient has mild, constant, variable symptoms (numbness and achiness). The severity and irritability are low. I was very confident that

18. Objective Exam • Observation: Forward head posture- mild, L shoulder elevation with scapular anterior tilt, no visible atrophy of hand, arm or shoulder musculature • Cranial nerve exam- negative • DTR: Tricep and Brachioradialis 2+ B; Bicep: R 2+, L 1+ • Sensation testing: C2-C4 normal; C5 and C6 on L abnormal; C7-T1 normal

19. Objective Exam • Myotome assessment: C2-C7 WNL • Cervical ROM: • Flexion- chin to chest- felt pull at posterior lower cervical spine; OP clear • Extension- 70 degrees- no familiar symptoms; OP to 75- stiffness, no sx • Rotation- No limitation- no familiar symptoms; felt pull at L posterior scap/ shoulder with R rotation; OP clear • SB- stretch felt on L side- w/ R SB; full motion- OP clear; no sx w/ Spurling’s

20. Thoughts at this time • At this point I was a little confused because I was expecting to find that cervical motions could provoke his symptoms. The lack of a comparable sign with cervical ROM led me to look at cervical PAIVM next.

21. Objective Exam • Cervical PAIVM: • C2-T1: UPA and CPA • Graded progression to IV • Prone; neutral, in extension, in rotation • No symptoms produced/increased; hypomobile C4-T1 • Thoracic PAIVM: • Hypomobility present T2-T8 • No comparable symptoms, Grade IV • Palpation: UT- tight, SCM -, scalenes -, suboccipital area -, levatorscap-tight

22. Thoughts at this time • Although I gained a good deal of information, at this time I was frustrated that I had not had any symptom provocation where I expected. I then suspected cervical radiculopathy less, and had to re-organize my thoughts.

23. Objective • Supine position: • Distraction: no change • ULTTA: Pt reported increase in achiness: full ER, visual observation of elbow extension: 100 degrees; Full on R • Radial nerve tension test: Intensified L hand numbness

24. Thoughts at this time • At this time I had ~10 minutes left until my next patient was due. I felt like I reached a treatment threshold, but that I still had some holes to fill.

25. Treatment • Manual Therapy: • Supine Radial nerve slider • Pt reported ~25% reduction in abnormal sensation and achiness (4/10 achiness to 3/10) • I felt like I didn’t have a good reason for choosing a slider vs a tensioner, but the treatment made a difference

26. HEP • 1. Standing radial nerve glide • 10 reps x 2 • Immediate reduction in intensity of hand numbness • 2. Levator scapula stretch • 3 x 20 seconds • Short term abolition of thumb/finger symptoms • 3. Upper trap stretch • Tightness present • Discordant- not a good selection

27. Exam and Initial Treatment Reflections • My previous case, and recent case discussions led me to put cervical radiculopathy and/or C6 involvement at the top of my list. I was able to find enough information to get to a treatment threshold, but feel like I hadn’t exactly nailed down exactly where the problem was. The treatment yielded more information.

28. Working Hypothesis • 1. Cervical radiculopathy • Location of symptoms, posture, numbness, symptoms change after prolonged position; - Spurling’s, -Distraction, - cervical motion causing symptoms • 2. C6 involvement ? • Location of symptoms; Unable to provoke symptoms at c-spine, no cervical motions caused symptoms • 3. Radial nerve involvement • Location of symptoms, Upper limb tension test w/ radial nerve bias produced comparable sign • 4. Thoracic outlet syndrome • Location of symptoms; did not test at 1st visit • 5. Shoulder referral- Did not test 1st visit • 6. Muscle referral- No sx w/ palpation

29. Prognosis • Very good prognosis. Motivated patient. Low severity and irritability. Basic exercises and manual therapy reduced symptoms dramatically. Addressing posture could be beneficial for long term.

30. Discharge Planning • With the rapid change in symptoms with stretching and nerve gliding, I expected him to respond quickly. I expected 4-5 visits for progression, and to teach him self-management techniques.

31. Plan for 2nd Visit • Better: Review HEP, assess 1st rib, assess for TOS, assess pec minor • Worse: Soft tissue mobilization in distribution of radial nerve; soft tissue mobilization of possible areas of entrapment of radial nerve • Same: Add passive radial nerve glides, with possible addition of lower cervical lateral glides

32. 2nd Visit • Pt reported a 60% improvement (greatly reduced numbness when he wakes up, and takes ~15 minutes of driving with the arm in provoking position for ache/numbness to increase; worked in yard over weekend and maintained improvement ) • Review/perform previous treatment + CRLF test on L- ache in lateral arm produced- 1st rib manipulation Pec minor- tight and tender; not comparable CT junction distraction manipulation: full extension with OP

33. 2nd Visit -At this visit I realized that I did not perform a slump test. No symptoms present during slump, or change of head position -Shoulder ROM: full motion: flexion, IR/ER at 0 degrees abduction Abduction: to 90 degrees: produced upper arm/forearm achiness at this point -GH joint mobility: A/P hypomobile, no reproduction of symptoms

34. 3rd Visit • Pt reports 75% overall change in symptoms (NDI 4/50,quickDASH 13/55) • ULTTA: elbow extension to 150 degrees • Mobilization of lower cervical spine with UE in upper limb tension bias for radial and median nerves • C5-C7, 3 x 1:00 each • Symptoms abolished at end of session • HEP given: sustained upper limb tension position for radial and median nerves with cervical retraction

35. Reflection following 2nd and 3rd visits • I continue to feel less confident with nerve gliding interventions. I also continue to mix interventions directly related to the concordant sign, and chasing interventions related to a discordant sign or impairment. I would like input on when to move on from assessing PAIVM (I feel like I should have been able to find something in that region). This is why I went to treat the cervical spine with mobilization w/ upper limb tension. I would also like to find a way to have a more objective measurement of numbness.

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