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EIM -104 Management of Cervicothoracic Disorders Section 4 Case-based Discussion Week 6

Mike Jones, PT, MHS, OCS, MTC Board Certified in Orthopaedic Physical Therapy Fellow-in-Training, EIM Orthopaedic Manual Physical Therapy Fellowship Program. EIM -104 Management of Cervicothoracic Disorders Section 4 Case-based Discussion Week 6. Rationale for Case Selection.

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EIM -104 Management of Cervicothoracic Disorders Section 4 Case-based Discussion Week 6

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  1. Mike Jones, PT, MHS, OCS, MTC Board Certified in Orthopaedic Physical Therapy Fellow-in-Training, EIM Orthopaedic Manual Physical Therapy Fellowship Program EIM -104Management of Cervicothoracic DisordersSection 4Case-based DiscussionWeek 6

  2. Rationale for Case Selection • Presentation of combined upper and lower motor neuron symptoms • Progression of manual therapy techniques through episode of care

  3. Subjective Examination • Patient Profile • Age • 40 • Gender • Female • Occupation • Homemaker involving variable demands of lifting, reaching, pushing, and pulling • Recreation • Attending her children’s sporting events involving prolonged sitting on bleachers several times per week

  4. Subjective Examination • Chief Complaint • Left-sided neck, upper back and shoulder pain, periodic headaches, and periodic pain and parasthesias into left hand

  5. Subjective Examination P2 Int Ache P1 CV Ache • Body Diagram P3 Int Shooting P4 Int Parasthesias

  6. Subjective Examination • Pain Scale • P1 • Average 5/10, Worst 8/10, Best 1/10 • P2 • Average 4/10, Worst 8/10, Best 0/10 • P3 • Average 4/10, Worst 8/10, Best 0/10 • P4 • Intermittent parasthesias

  7. Subjective Examination • Aggravating Factors • P1 • Looking up • Turning head right or left • Reaching or lifting with left UE • Sitting unsupported as on bleachers • P2 • Looking up • Turning head right or left • Sitting unsupported as on bleachers

  8. Subjective Examination • Aggravating Factors • P3 • Turning head left • Sitting unsupported as on bleachers • P4 • Sitting unsupported as on bleachers

  9. Subjective Examination • Easing Factors • P1 • Sitting with head, neck, upper back, and UEs supported • P2 • Sitting with head, neck, upper back, and UEs supported • P3 • Sitting with head, neck, upper back, and UEs supported • P4 • Sitting with head, neck, upper back, and UEs supported

  10. Subjective Examination • Relationship between symptoms • P1 precedes all other symptoms • P2 may precede P3 and P4 with unsupported sitting • P4 occurs in association with P3

  11. Subjective Examination • 24-hour Behavior • Best in morning • Worsens through day • Difficulty getting to sleep at night • Periodic waking due to pain which is improved with position change

  12. Subjective Examination • Current History • Idiopathic onset of symptoms 2 weeks prior to initial visit in PT, worsened until current level maintained over past week

  13. Subjective Examination • Past History • Periodic episodes of less intense neck pain and headaches for years, but no complaints of UE symptoms previously

  14. Subjective Examination • Medications • Naproxen • Flexeril • Hypertension medication • Statin medication

  15. Subjective Examination • Previous Treatment • Medications • Little effect • Chiropractic • 1 visit with partial, temporary relief lasting approximately 1 day

  16. Subjective Examination • Diagnostic Imaging • None

  17. Subjective Examination • General Health/Review of Systems • Hypertension and hyperlipidemia well controlled by medications • History of seizure at age 1 with resultant scarring to left side of brain leading to persistent motor control deficits through right UE and LE; no acute change in these long-standing symptoms noted • History of child birth x2 with two teenage children

  18. Subjective Examination • Screening • Denies the following • Bowel or bladder dysfunction • Saddle anesthesias • Weight loss • General constitutional symptoms • Recent illness or infection • Dizziness • Notes some long-standing balance difficulties, but no acute change in these symptoms

  19. Subjective Examination • Screening • Depression screen • Negative • Elevated fear avoidance beliefs screen • Negative

  20. Subjective Examination • Patient Goals • Reduce pain and improve abilities with daily activities • Improve ability to sit unsupported at her children’s sporting events

  21. Clinical Reasoning • Potential Structural Involvement • Joints • Cervical • Upper thoracic • Shoulder • Elbow • Wrist/hand

  22. Clinical Reasoning • Potential Structural Involvement • Muscles • Posterior cervical and upper thoracic • Upper trapezius • Levator scapulae • Supraspinatus • Infraspinatus • Teres minor • Deltoid • Tricep • Bicep

  23. Clinical Reasoning • Potential Structural Involvement • Referring structures • Lower cervical and upper thoracic nerve roots • Lower cervical and upper thoracic intervertebral discs • Heart • Cervical arteries

  24. Clinical Reasoning • Potential Structural Involvement • Other • Tumor • Abscess

  25. Clinical Reasoning • Subjective Asterisk Signs • Turning head as with driving • Reaching and lifting tasks with left UE • Sitting unsupported as on bleachers • Initiation and maintenance of sleep

  26. Clinical Reasoning • SINSS Presentation • P1 • Severity: Moderate • Irritability: Severe • Nature: Mechanical originating from cervical spine and possibly left shoulder • Stage: Acute • Stability: Stable

  27. Clinical Reasoning • SINSS Presentation • P2 • Severity: Moderate • Irritability: Moderate • Nature: Mechanical originating from cervical spine • Stage: Subacute • Stability: Stable

  28. Clinical Reasoning • SINSS Presentation • P3 • Severity: Moderate • Irritability: Moderate • Nature: Radicular pain originating from cervical spine • Stage: Subacute • Stability: Stable

  29. Clinical Reasoning • SINSS Presentation • P4 • Severity: Mild • Irritability: Moderate • Nature: Radicular originating from cervical spine • Stage: Subacute • Stability: Stable

  30. Clinical Reasoning • Hypotheses • Primary • Cervical radiculopathy • Differential diagnosis • Left shoulder mechanical symptoms • Cervical myelopathy

  31. Clinical Reasoning • Objective Examination Planning • Gentle examination indicated • P1 may be minimally reproduced • Efforts will be made to avoid reproducing P2, P3, and P4 • Expect comparable signs to be easy to reproduce • Careful attention will be paid to neurological examination based upon previous history of neurological impairments

  32. Objective Examination • Observation • Sits and stands with forward head posturing, increased thoracic kyphosis, and increased cervical lordosis • Mild scoliosis with compensatory left side bend through lumbar region due to apparent structural leg length discrepancy with right LE shorter than left • Atrophy noted through right hand intrinsics and, to a lesser degree, right thigh and lower leg • Mild clawing of hand, flexion of wrist, pronation of forearm, and flexion of elbow on right

  33. Objective Examination • Neurological Testing • Dermatomes • WNL • Myotomes • Weakness of left elbow extensors, wrist flexors, and wrist extensors • Weakness of right wrist flexors, wrist extensors, thumb radial abductors, finger flexors, and finger abductors • Reflexes • Unable to elicit triceps reflex on left • Hyperreflexive UE and LE reflexes on right • Babinski and clonus positive on right

  34. Objective Examination • Range of Motion

  35. Objective Examination • Range of Motion

  36. Objective Examination • Range of Motion • Right shoulder PROM mildly limited and painful with pain at tissue resistance in all planes

  37. Objective Examination • Manual Muscle Testing

  38. Objective Examination • Manual Muscle Testing

  39. Objective Examination • Special Tests • Sharps-Purser Test • Negative • Alar Ligament Laxity Test • Negative

  40. Objective Examination • Special Tests • Spurling’s Test • Positive on left for reproduction of neck, shoulder, and distal UE symptoms • Cervical Distraction Test • Positive for alleviation of left UE symptoms • ULTT A • Positive on left for reproduction of symptoms with reduced symptoms noted with ipsilateralsidebend of neck

  41. Objective Examination • Palpation • Condition • Tenderness and increased muscle tone through left upper trapezius and levator scapulae • Tenderness along left long head of bicep tendon

  42. Objective Examination • Palpation • Position • Unremarkable for grossly appreciated asymmetries

  43. Objective Examination • Palpation • Mobility • Local pain and hypomobility with central and left unilateral PAs at C2 through C7 • Local and left shoulder pain and hypomobility with downglide left particularly at C6-7

  44. Assessment • Primary hypotheses • Cervical radiculopathy with involvement of left C7 nerve root • Mechanical left shoulder pain • Objective asterisk signs • Cervical AROM • Left shoulder AROM • Left UE strength testing

  45. Assessment • Additional Concerns • Presence of upper motor neuron signs through right UE and LE appear to be related to long-standing neurological impairments with no recent changes described in status with respect to additional upper motor neuron signs • Current symptoms of neck and left UE pain readily reproduced and alleviated with mechanical testing of neck and, in part, left shoulder • Left UE neurological signs appear to be of lower motor neuron origin

  46. Prognosis • Good • No obvious psychosocial factors serving as negative influences • Recent onset of symptoms

  47. Treatment • Initial treatment at time of evaluation • Interventions • Posture re-education emphasizing support of thorax and UEs • Home program • Gentle upper cervical flexion in sitting or supine • Positional distraction for cervical spine in flexion with slight right side bend • Supine Mechanical Cervical Traction • Flexed 20°, 30 seconds on at 16 lbs. and 10 seconds off for a total time of 15 minutes

  48. Treatment • Initial treatment at time of evaluation • Response • Reduced complaints of neck and left UE pain following mechanical cervical traction

  49. Treatment • Second visit • Response to previous treatment • Reduced frequency and intensity of neck and left UE symptoms • Able to reduce symptoms with home program performance • Asterisk signs • Sleep improved • Still very difficult to sit unsupported • Objective asterisks avoided due to irritability of symptoms

  50. Treatment • Second visit • Interventions • Inhibitory soft tissue mobilization left upper trapezius and levator scapulae • Left unilateral PA C2 through C7 up to grade III on all excluding only grade II as tolerated at C6 • Home program reviewed • Mechanical cervical traction as applied previously

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