Lets go!

1. Lets go!

2. Patient Profile • 58 y.o. female, works full time as a teacher. Active with going to the gym, primarily likes using the eliptical and stairmaster, general weight training • Chief complaint: “Constant tightness in my neck that leads to a headache about 3 days/week.” • Self Report inventories • Numeric pain scale • Best in the last week: 0/10 • Worst in the last week: 5/10 • Average in the last week: 3/10 • Neck Disability Index: 34%

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4. History of Current Episode • Duration of symptoms: 20 year hx of neck pain and HA • Mechanism of onset: insidious • Progression of symptoms since onset: greatly improved over time. “It used to get so bad I would have to go home and go straight to bed, and it was almost daily.” • Current status (improving, static, worsening): static • Treatment and response: felt all prior rx was helpful to some degree and had a cumulative effect over time: • chiropractic manipulation: for several years, several years ago • PT (primarily massage and exercise): last round approx 3 years ago, cx massage, generic UE exercise • massage: full body, including cx approx 2-3x/year

5. Previous History • Previous Episodes: severe HA requiring going to bed • Contributing Factors: posture, work as teacher involving sitting for computer work, some bending to work with children. Resting posture promotes upper cx extension, bending promotes upper cx extension, and pt likely remains/sustains posture during computer work. • Previous Treatment:chiro, PT, massage • Medical History/Co-morbidities: approx 2006 bilateral carpal tunnel sx, left ulnar nerve relocation, L5 spondy, osteoporosis

6. Aggravating/Easing Factors Worst area: upper cx, rams-horn HA Best: Preferred Position of Rest: lying down in any position 24 hour behavior: best in am, worst by pm

7. Red & Yellow Flag Screen • General Health - good, all clear • Age 50 with history of cancer -no • Cord: Clumsiness in hands, disturbance of gait suggestive of spasticity: -no • Cauda Equina: -no • Steroids or anticoagulants: -no • Numbness and tingling in the hands and feet: -no • 5 D’s (dizziness, diploplia, dysphagia, dysarthria) -no • Yellow flags? FABQ/Depression -no

8. Working Hypotheses • Hypothesis: upper cx dysfunction, rests in upper cx extension; “high-low”. Onset of upper cx, primarily C2 based on rams-horn distribution, HA at end of day after likely functioning in her preferred posture involving upper cx extension. Syx b/w shoulder blades likely thoracic in nature given the large area and behavior of syx, however, need to rule out Cloward’s sign/cx referral • Evidence supporting: observed posture, distribution and behavior of syx • Evidence against: exhibits sharp lordotic curve with “step” at mid-cx. Possible that syx are also generated from this area.

9. Presentation

10. Objective Examination • Observation • Affect: very happy, energetic • Fitness: general good m. tone, clearly healthy and active • Gait: normal, maintains fwd head posture • Posture • Habitual: fwd head, rounded shoulders • Spinal contours: sharp cx lordotic curve • Signs of muscle imbalance: weak deep cx flexors, scap retractors

11. Neurological Examination • Reflex: normal • Dermatome: decreased sensation bilateral thumb, left pinky (correlates to hx of carpal tunnel and ulnar nerve sx) • Myotome: normal

12. Active Range of Motion Cervical

13. Active Range of Motion Thoracic

14. Other tests • Deep cx flexor strength: weak, unable to hold without compensation

15. Palpation Findings: PPIVMS Palpation Findings:

16. Palpation Findings: PAIVMS

17. Assessment Following the Objective: Review and re-rank your hypotheses • Hypothesis - upper cx extension dysfunction, upper cx HA • Evidence supporting - comparable cx pain with palpation suboccipitals/upper cx exam. No reproduction of thoracic syx with cx PAIVMs. • Evidence against

18. Select Subjective and Objective Asterisks

19. Treatment Day 1

20. Assessment Following Treatment • Working hypothesis: upper cx dysfunction, HA, true thoracic syx • Initial hypothesis confirmed • Classification: Cervical dysfunction with HA • clinical syndrome apparent: upper cx related HA, “high-low” • Assessment of Presentation remained

21. Visit # 2 Assessment

22. TreatmentVisit 2

23. Visit 3: 5 days later • S: No return of HA. Cx syx 50-60% improved, primarily R-sided. Worse with computer work while sitting >20 min (this is her new baseline). Quickly ease with postural correction/chin tuck. • O: AROM: *R-sided syx at end-range R & L upper cx rotation, less range with L, approx 35deg. • PAIVMs: *C2 UPA (prone) in R rotation, gunky

24. Visit 3 Rx • gr IV R U PA C2 in R rotation • decreasing resistance and syx during rx • AROM: 60% decrease in cx syx with R & L upper cx rotation, improvement in quality and quantity of range, L upper-cx rotation range < R, approx 40deg • supine gr IV L rotation/upglide C2 • decreasing resistance and syx during rx • upper-cx AROM: near elimination of syx • upper cx pump stretch central and with bias to R side - passive and with active upper cx flexion: equal R and L upper cx rotation, elimination of syx • Therex: same: deep cx flexor strengthening, upper thoracic dorsal glide/self-mob, prone over ball postural endurance 29

25. Visit 4: 2 days later • S: no return of HA or cx syx for approx 24 hrs following last visit. Awoke with HA this a.m., went away during workout at gym, but slowly returned at a lower intensity. Noted “bulged” muscle on R side (middle scalene) of neck accompanied HA. Pt could relieve HA with rubbing of this muscle while moving neck. No relief with upper cx flexion ex. • O: *upper cx ext -> high R “muscle” pain at end range, *R upper cx rotation less than L -> high R “joint” pain at end range, less range than previous visit, approx 35deg • Palpation: spasm, tenderness along R side neck/scalene 30 30

26. Visit 4 Rx • STM/muscle bending R scalene/R lateral neck with contract/relax into L rotation (actively rotating R, relaxing to L) • softening and decreasing tenderness during rx • elimination of resting syx after rx. Cx syx with R upper-cx rotation. • L side-lying R scalene STM down to 1st rib with active scap depression. Gr IV caudal glide 1st rib because of attachment of scalene. • no resting syx, no syx with R upper cx rotation, full range • Therex: self stretch/STM to R cx spine with L SB/scap depression 31 31

27. Visit 5: 5 days later • S: Rx soreness after last visit, but no return of HA. Mild and infrequent return of cx syx, quickly relieved with postural correction and self-STM to R cx spine. “Tennis balls really help the thoracic area”. • O: *R-sided syx with L upper cx rotation, less range than R • Rx: • supine gr IV L rotation/upglide C2 - added contract/relax • decreasing resistance and syx during rx • AROM: near elimination of syx • R OA gapping, targeting soft tissues (gap with L SB) significant improvement in range and syx, 45deg • upper cx pump stretch with R bias ->elimination of syx • Therex: reviewed HEP 32 32

28. Visit 6: 2 days later • S: Rx soreness remainder of day after last visit. “I can go lots of hours without even noticing my neck now”. Around 5:00 begins to notice need to stretch to fend off syx while doing mostly seated work. • O: R and L upper cx rotation clear of syx, L limited in range vs R with “stretch” with OP into L rotation • Rx: • Gr IV C1-C2 L rotation • improvement in L upper-cx rotation quality • R OA gapping • significant improvement of L upper-cx rotation, 45 deg -active and with OP, and at rest “I feel so much looser!” • Therex: self-OA traction/gapping w/ strap or hand, upper cx active stretch. Reviewed all other HEP. 33 33

29. Assessment Functional Asterisks and Impairments