Evidence in Motion, LLC

1. Evidence in Motion, LLC Cervical Written Case February 1, 2013 Matt Anderson DPT, OCS, CSCS EIM OMPT Fellow in Training

2. Rationale for choice of this case • Retrospective analysis of this case helped me to identify the following problems: • 1. Poor use of SINSS to guide exam/rx • 2. Poor integration of pain science and chronic pain education/intervention • 3. Difficulty determining severity and irritability due to patient exaggeration of symptoms • 4. Exercise selection and progression needs to improve

3. Patient Information • 28 y/o white female; ectomorph • Referred to PT after an ER visit • PMH: • Adjustment disorder with depression • DJD • Epidermal cyst • Chief complaint: pain in neck, back, shoulder, headaches

4. Body Chart • Aggravating factors • Turning head, sleeping • Driving, using L arm • Bending, lifting • Prolonged sit/stand • Alleviating factors • Flexeril/naproxen • Salt bath, back brace • Heat, massage

5. Subjective • Known injury: MVC x 2 (2006 and 2011) with constant pain since then • NDI score: 76% • Red flag assessment: no gait deviation, no b/b incontinence, no h/o cardiac problems, no dysphagia, dysarthria, dizziness or diploplia • Spent 6 years in the Coast Guard as a pilot- reports that she had neck pain during this time due to her helmet

6. SINSS • Severity: High (reports that she can’t work, and required assistance from her boyfriend for some activities in her home; has intermittently worn a soft collar neck brace) • Irritability: High (quickly comes on, can quickly return to baseline or linger for several hours) • Nature: Mechanical cervical pain- non-radicular; Shoulder instability; Psychosocial factors • Stage: Chronic • Stability: Getting worse Yellow Flags: Fearful of movement of neck and shoulder, belief that serious pathology could be present

7. Objective • Cervical AROM: • -extension 60 degrees • Flexion WNL • SB 45 degrees • Rotation L 50, R 65 • Cervical PROM (OP not tested): • Extension Full • Flexion Full • Rotation L 60, R 70

8. Objective • MMT: RUE WFL; LUE: 4/5 triceps, wrist ext, finger abd, thumb ext; bicep too painful to assess • Hand grip dynamometry: R 32 kg, L 10 kg • Shoulder A/PROM: 160 bilateral w/ guarding • CPA grade I C2 to CT junction: hypomobile with spasm and guarding

9. Objective • T-spine: hypomobile with CPA’s • Sensation: intact • DTR: 1+ BUE/BLE, no clonus/hoffmans • 4/4 negative for cx radiculopathy • Sharp-Purser: negative • Palpable tenderness: L levator scap, L upper trapezius, L infraspinatus/teres minor (produced comparable shoulder pain)

10. Assessment • The patient was fearful of movement of both the cervical spine and the L shoulder. She has a very thin build, with winging scapulae. She has moderately excessive thoracic kyphosis, with forward head posture. Differentiation of shoulder problem difficult as all special tests were positive (O’Briens, ER weakness, Neers, Apprehension).

11. Treatment (day 1) • Manual Therapy: • Supine CT junction manipulation • Cavitation noted • 10 degree improvement in extension/rotation • Supine HVLA flexion manipulation • T3 on T4 • Cavitation Noted; Stress on L shoulder avoided • Therapeutic Exercise: • Pain free cervical AROM, Gentle cervical retraction, Gentle scapular retraction

12. Plan • From the note: • “chronic cervicothoracic pain seems musculoskeletal, with no true radicular presentation. Glenohumeral and scapular instability in L shoulder present, as well. Interventions to include thrust and non-thrust manual techniques, AROM of cervicothoracic region, scapular and cervical stabilization activity, trigger point dry needling, and postural awareness training. The patient seems very motivated to improve.”

13. STG/LTG • STG/LTG: 1. I w/ HEP in 10 Tx • 2. 10% or greater decrease in NDI score in 10 Tx • 3. 25% improvement sleep quality and quantity in 10 Tx • 4. 25% decreased pain with driving in 10 Tx

14. Treatment (day 2) • Pt reported that after the first session, she had a reduction in symptoms at the neck, with improvement in tolerance of rotation, and she slept ~1.5 hours more than usual • Trigger point dry needling: • Upper trap, Levator scap, infraspinatus, teres minor • Soreness present following treatment • Reduction in familiar pain at shoulder • Shoulder flexion to 170 L side

15. Treatment (day 2) • Therepeutic exercise: • Upper trap, levator scap stretches • Quadruped slide, roll and lift for scap control/ lower trap firing • Diaphragmatic breathing to reduce accessory muscle activity

16. Treatment (day 3) • The pt reported a very high level of pain. The increase in pain was linked to her animals being killed. • She requested continuing with dry needling, as it helped at previous treatment • Diaphragmatic breathing helped her get to sleep

17. Treatment (day 3) • Dry Needling: • Cervical multifidi (C3/C4/C5), upper trap, rhomboids, teres minor • Therex: • Rhythmic stabilization- scapula/GH joint • Supine-gentle • Kinesiotaping: • Clavicle, supraspinatus, infraspinatus

18. Treatment (day 3) • Soreness present in musculature which was dry needled • Reported improvement in tolerance of movement from 0-120 shoulder elevation • No increase in pain with exercises following taping; improvement in stability at the GH joint reported

19. Evidence in Motion, LLC Cervical Written Case 2/1/2013 Matt Anderson DPT, OCS, CSCS EIM OMPT Fellow in Training