Transcript Patient Profile - Fearon Physical Therapy

Patient Profile
• 24 year-old, female, single physical therapist, mountain biker
• Chief complaint: Intermittent headache in the occipital lobe
– Secondary complaint of intermittent tightness and pain in
upper C-spine
• Self Report inventories
– Numeric pain scale
• Best in the last week: 1/10
• Worst in the last week: 8/10
• Average in the last week: 4/10
– Neck Disability Index: **%
– Fear Avoidance Belief Scale: **/64
• Physical Activity Subscale: **/ 24
• Work Subscale : **/42
Patient Specific Functional Scale
Functional Impairment:
Where 0 = unable and 10 = able to perform at pre-injury level
Total
Score
**
1) Mountain biking
2
2) Work all day
4
3) Deskwork 30 minutes
6
Total 12/3 activities
PSFS Total
4
Body Chart
P1: Occipital lobe HA:
Intermittent
x
X
P2: tightness constant
& intermittent pain
x
Relationship: when constant
tightness increases
-it leads to Cx pain
- which leads to HA
x
1)Insert Text Box then type an x or copy and paste from existing
2) Resize auto shapes at will
3) When body chart is complete: Group symbols
P1:
X
P2:
P3:
P4:
History of Current Episode
• Duration of symptoms:
– HA 2 years, Cx tightness
– pain last 6-8 months
• Mechanism of onset:
insidious
• Progression of symptoms since onset:
gradual escalation of
HA, cervical tightness over the last 6 months
• Current status:
worsening
• Treatment and response:
-migraine meds: minimal effect
-PT (joint mobilization/soft tissue mobilization/mech traction:
no change
-DC 1x temporary relief
Previous History
• Previous Episodes: progressive increase over 2 years
• Contributing Factors: 10 year history as a gymnast
• Previous Treatment: PT/DC/Meds no help
• Medical History/Co-morbidities:
– clear
Aggravating/Easing Factors
Area
Aggravating Activity
Time /Pain Level
Eases
Time to subside
P2-P1 Mountain bike
1-2 hours/0-8
Supine lying
4 hours
P2-P1 Work as PT
8 hours/0-2
supine
Full nights rest
P2
30 min/0-4
standing
5 min
Desk work
Worst area:
Best:
occipital lobe extending into parietal and temporal lobe
Preferred Position of Rest: Supine
24 Hour Behavior
• Night: sleeps through
• A.M.: best, wakes with only cervical tightness
• Day: activity dependent
Red Flag Screen
• General Health: clear
• Age 50 with history of cancer :
clear
• Cord: Clumsiness in hands, disturbance of gait suggestive of
spasticity: clear
• Cauda Equina :
clear
• Steroids or anticoagulants :
clear
• Numbness and tingling in the hands and feet : clear
• 5 D’s (dizziness, diploplia, dysphagia, dysarthria) :
clear
Yellow Flag Screen
• FABQ Score:
ND )o:
• Depression Inventory :
clear
Possible Hypotheses
• Joints under the area: O/1, 1/2; Cx column
• Joints or other structures which may refer into the area of symptoms:
-intercranial, GON, mid cervical facet column
• Contractile structures:
-sub-occipitals, upper traps, levator
• Other structures which must be examined or ruled out :
-upper Cx, lower Cx
• Are any clinical patterns evident:
-neck pain with HA
Current Hypotheses
Hypothesis
Supporting Evidence
Cervicogenic HA
Primary complaint
Hi-Low presentation
Evidence Not supporting
Presentation
Area
P1
P2
Severity
non
non
Has stopped no
activity
Irritability
Moderate - High
moderate
Large dose of
activity to
make much worse
Long time to settle
Nature
mechanical
Stage
chronic
Stability
worsening
Plan of the Objective Examination
•
•
•
•
•
Does the nature of the condition or presence of co-morbidities indicate caution?
10 year gymnast, downhill MB, HA
Will you limit the amount of examination?
– Prioritize rather than limit, responding accordingly
Will you limit the vigor? :
– Examine to P1:
HA
– Examine to limit of active range: I want to see the willingness to move
– Add overpressure: PRN, but I do want a sense of end feel
– Use repeated movements:
unlikely
– Use sustained overpressure, combined movements: PRN
Are special tests indicated?
– UCI : gymnast, MB, nature of complaint
What structures will you examine on day 1?
– UCx—Upper T spinal segments, sub-occipital MM, UT, LS, Scalene, DNF
– GON
Plan of the Objective Examination
• Do you expect the comparable sign to be easy or hard to find?
– Cx tightness: “constant” , increase may require sustained or repeated
– Cx pain: harder, dependent on duration of activity
– HA: hardest: time dependent, neck pain first
• What test or movement do you think will reproduce the comparable sign?
– U Cx extension/ repeated / OP/sustained OP
• Are there contributing factors which must be examined?
– Postural predisposition: Upper T spine, scapulo thoracic MM
Objective Examination
• Observation
– Affect: youthful zeal
– Fitness: fit
– Gait: athletic
• Posture
– Habitual: UC extension ( Forward head )
– Spinal curvature: T spine flat, kyphosis all UT
•
Cervical lordosis flattened, U Cx extension
– Signs of muscle imbalance: posterior MM dominating anterior
• Functional Screens
– look up
– Arms over head
Active Range of Motion Thoracic
Range
Deviation
Symptoms
Limit of
Range
Flexion
limited
no
no
end
Extension
limited
No
No
end
Lateral flexion left
Lateral flexion right
RR
RL
Active Range of Motion Cervical
Range
Deviation
Symptoms
Limit of
Range
Flexion*
0 -10
No lordosis
reversal
“feels good”
Extension**
0-15
--
Slight reproduction Stops
of her Cx pain
because of
her pain
Rotation left
60
-clunk
Slight U Cx pain
Simultaneous
pain &
resistance
Rotation right **
45
--
Her tightness U Cx
resistance
Lateral flexion
left
0 – 30
click
Slight pain R U Cx
apprehensio
n
Lateral flexion
right
0 -20
--
painfree
end
none
Feels good
end
Retraction (dorsal available
glide)
end
Active Range of Motion Cervical
Range
Deviation
Symptoms
Limit of
Range
Extension**
0-15
--
Slight
reproduction of
her Cx pain
Stops
because of
her pain
Flexion*
0 -10
No lordosis
reversal
“feels good”
End
Flexion OP
10 -20
--
“Feels better”
Stiff, elastic
end feel
Rotation R **
45
--
Tight U Cx
Resistance
U Cx stiff
elastic
RR OP
45-50
Increased tight
U CX stiff
Active Range of Motion Upper Cervical
Range
Deviation
Symptoms
Limit of
Range
Extension
limited
--
Her Cx pain ++
Due to pain
Flexion
minimal
--
“ feels good”
end
Flexion OP
0-5
--
“feels even
better”
Stiff, elastic
Rotation right
From 45 55
Cx stiffness
Stiff, elastic
end feel
Neurological Examination
•
•
•
•
•
•
•
•
Reflex:
WNL
Dermatome:
WNL
Myotome:
WNL
Hoffman’s:
no
Clonus:
no
Babinski:
no
Cranial Nerve examination :
WNL
Upper cervical ligamentous stability: positive for TVL laxity
Other tests
• Compression: no change
• Distraction: decreases Cx symptoms
• UCI testing:
Transverse ligament:
-movement associated with clunking sound & feel
-Sustained decreases HA
*
Alar: laxity R ( with LSB)
Palpation Findings: PPIVMS
Palpation Findings: hypertrophic Sub O, UT, LS
Range
End Feel
Symptoms
Reason for stop
Occiput C1
Hypo in flexion
Hyper in ext
Stiff
guarded
Better
Pain Cx
Limit
Guarding & Pain onset
C1
Hypo RR
Increased LR
Stiff
empty
Tightness increase
U Cx pain
Limit
pain
C2
limited
stiff
Slight Cx pain
Resistance > Pain
C3
limited
stiff
--
End range
C4
hyper
stiff
--
End range
C5
hyper
stiff
--
End Range
C6
Hypo +
stiff
--
End range
C7
Hypo++
Stiff
--
End range
Rib 1
Palpation Findings: PAIVMS
Range
End Feel
Symptoms
Reason for stop
Limited
Hard
MM gaurding
----
End range
C1 UPA R stiff
R1 then R2
Decreased
Limit
C1 UPA L
R1 then R2
painless
End range
O C1
stiff
C2 UPA R Stiff, limited
R1 then P1
Her Cx Pain
Her pain
C2 UPA L
R1 then P!
Her Cx pain
Her pain
C3
C4
C5
C6
C7
Stiff, limited
Assessment Following the Objective:
Review and re-rank your hypotheses
Hypothesis
Supporting Evidence
Question/Uncertainty
Upper Cervical
Instability
UCI testing
Upper Cx & cranial Symptoms
No imaging confirmation
Safety First?
Select Subjective and Objective Asterisks
Subjective /Functional
Asterisks
Desk work 30 min*
Objective Asterisks
PT work 8 hours*
RR 45: her tightness*
Extension 15: her Cx pain,
slight, but precise **
Flex 10, feels good*
Flex UC feels better*
Flex UC OP feels best **
Treatment Day 1
Technique/Intervention:
Sub-O physiologic lengthening
Patient /tissue response during
performance of technique:
Feels “great”
Intention of Technique :
Reduce provocative position of UC ext in
pain reducing motion
Reassess Subjective /Functional Asterisks
Reassess Objective Asterisks
“Tightness is gone” was constant
Flexion moves from 10 to 20
Exercise to support intervention: DNF
Trial of exercise: pain free, fatigues rapidly
Result: flexion improved
Patient Education/Instruction: posture out of Fwd head
Treatment Day 1
Technique/Intervention:
Posterior Glide O on A
Intention of Technique :
Restore osteo-kinematics at O-A
(in pain reducing motion)
Patient /tissue response during
performance of technique:
Feels “great”
Reassess Subjective /Functional Asterisks
Reassess Objective Asterisks
constant tightness is gone
Flexion moves from 10 to 30 with no
change in pain ( “feels better”)
Ext UC pain free
Ext improved from 15 - 30
OA stiffness/ MM gurrding decreased
Exercise to support intervention: DNF
Trial of exercise: pain free, fatigues rapidly
Result: flexion improved 30-35
extension improved from 15- 30
Patient Education/Instruction: posture out of Fwd head
Assessment Following the Treatment:
1)Review and re-rank your hypotheses
2) What is the impact of treatment on the working hypothesis
Hypothesis
Supporting Evidence
UCI
OE & imaging
Cx pain with HA
presentation
Question/Uncertainty
Assessment Following Treatment
• Working hypothesis: Neck Pain with HA, UC
• Was your initial hypothesis confirmed, clarified, modified or rejected?
– Confirmed
• Can the disorder be classified or is a clinical syndrome apparent?
• HA, UCI
• Hypo-mobility high and low
• Did your assessment of Presentation change?
– Severity:
– Irritability: Decreased
– Nature :
– Stage:
– Stability:
Prognosis
• Expected level and rate of recovery:
• Functionally inconsequential management of pathological state
• Time frame and number of visits:
• Unclear but optimistic with rate of change in 1 visit
• Factors which will promote or impede recovery:
– Skeletal structure
– Posture in desk work and at PT
– Mountain biking in the face of potential disaster
• Likelihood of recurrence:
• High without patient compliance
Plan for the next session
• Is further examination or clarification required to develop the working
hypothesis, rule out other structures or investigate contributing factors?
• Demands exam of UC and thoracic hypo-mobility to determine value in
restoring movement
• What will you do if the patient returns:
– Better: Examine UC & T, Treat accordingly. Keep 3 established
treatments
– Worse: Run from room, hair on fire
– Unchanged: consider U Cx hypo findings in C1, C2 & T spine
Visit # 2 Assessment
Subjective: Much improved
Time from start of care: 7 days
Time from last visit: 3 days
Effect of the last treatment: “Great”
Reassess Subjective /Functional Asterisks
Reassess Objective Asterisks
No return of constant tightness
Desk work 1 hour: increased Cx pain
prodrome of HA
immediately abated with standing
U Cx extension pain-free ( retained )
U Cx Flex OP elastic EF, “feels better”
After work 8 hours ISQ
RR 45 tight U Cx
C1 UPA R: Stiff with decreased in Cx Sm
grade IV
C1 UPA L: Stiff & painless grade IV
Treatment Visit 2
Technique/Intervention: UPA
R C1 IV
Intention of Technique :
change RR tightness
Patient /tissue response during
performance of technique:
R2 treatment zone, moves
back in range
“this feels good on my neck
pain”
Reassess Subjective /Functional Reassess Objective Asterisks
Asterisks
RR was 45 now 55, tightness
Reassess
• RR was 45 now 55 & tight
• C1 UPA R less stiff, “feels good”
• C2 UPA R stiff & pain** IV
• C2 UPA L stiff & pain IV
Treatment Visit 2
Technique/Intervention:
UPA R C2 IV
Intention of Technique :
change her pain in the
segment of hypomobility
Patient /tissue response during
performance of technique:
R1 then P1
treatment zone R1
IV-
Reassess Subjective /Functional Reassess Objective Asterisks
Asterisks
RR was 55 now 60, “less
tightness”
C2 UPA R stiff & pain* IV
R1 –R2—P1
• Round 2 UPA C2 R IV –
– R2 moves further toward B
– RR 65
• Sub O pump stretch with active recruitment of
antagonists (DNF)
• Posterior glide O on A , C2 blocked
Treatment Visit 2
Exercise to support intervention:
Continue DNF training
Postural exercise
Trial of exercise:
added self mob with fixating C2, RR
Result:
improves ease of motion per patient
Patient Education/Instruction:
as above with POSTURE
break up sitting at desk every hour
NO MB
Visit # 3 Assessment
Subjective: Much improved
Time from start of care: 2 weeks
Time from last visit: 1 week
Effect of the last treatment: “Great”
Reassess Subjective /Functional Asterisks
Reassess Objective Asterisks
No return of constant tightness
Desk work 1 hour: stands, no Sx
U Cx extension pain-free ( retained )
U Cx Flex OP elastic EF no Sx
After work 8 hours 80% decrease Cx pain,
no HA
RR 65 tight U Cx
C1 UPA L: Stiff IV R1 then R2 then P1 Cx
C2 UPA R: Stiff IV R1 -- R2 then P1
Treatment visit 3
• C1 L UPA IV
• C2 R UPA IV –
– No change
• C1 R UPA IV
75 RR pain free tight w OP
• DNF training in vertical
• Upper T extension mobilization with Cx
Flexion retained
Visit 4-7
• DNF training
– Supine
– Supine on ball
– vertical
• Thoracic extension
– Self mob
– Strength training
Assessment Functional Asterisks and Impairments
At initial evaluation
Current Status.
Extension:
15: her Cx pain, slightly **
45 painless
RR:
60 her tightness*
75 Sx free
Flex:
10, feels good*
40 Sx free
Patient Specific Functional Scale
Functional Impairment:
Where 0 = unable and 10 = able to perform at preinjury level
Initial
Score
**
17
days
1) Mountain biking
2
---
--
2) Work all day
4
4
9
3) Deskwork 30 minutes
6
6
10
4
5
9.5
Total 12/3 activities
PSFS Total
Post Treatment Assessment and Plan
Risky Circumstances
Cautious Assessment
You could jump in
Or, look for the safe way