•

Patient Profile

43 year old male corrections officer , and father of two. Exercises regularly in the gym lifting weights. Has been off work on vacation , but has now moved to off work status due to his shoulder pain. Plans to return to work next week on light duty.

• Chief complaint: “ I re-tore the labrum in my right shoulder. “ and I don’t see how starting the physical therapy will help. I need an MRI and the insurance won’t due it until I have physical therapy. “ • He is complaining of right sided neck pain with radiation to the medial border of the scapula and right anterior shoulder pain.

Incidence and etiology

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Risk Factors for Neck Pain (Childs, et al., 2008) reviewed

publications published from 1996 through June 2007 to produce a clinical practice guideline covering risk factors, diagnosis, differential diagnosis, examination and interventions. They concluded that the following were risk factors for neck pain: – age (>40), – psychological health(worrisome attitude) and – poor quality of life (which certainly includes tobacco use). – – cycling as regular activity, less vitality, – – a long history of neck pain, and loss of strength in the hands.

Patient Self Report Inventories

• • • • Numeric Pain Rating Scale (NPRS) – Best in the last week: 6/10 – – Worst in the last week: 8/10 Average in the last week: 7/10 Neck Disability Index (NDI): 45% Fear Avoidance Belief Scale (FABQ): 32/64 – Physical Activity Subscale: 18/ 24 – Work Subscale : 16/42 Depression Screen: Negative – During the past month have you been bothered by feeling down, depressed or hopeless?

– During the past month have you been bothered by little interest or pleasure in doing things.

Patient Specific Functional Scale

Functional Impairment: Where 0 = unable and 10 = able to perform at pre-injury level

1) Reaching above shoulder height 2) Lifting weights at gym 3) Carrying his son (35 lbs) close to body 4) Sleep through the night 5) Turning the head to drive or look up

Total Score 3.2

3 2 4 3 4

P1:

Anterior shoulder pain, constant, deep ache, sharp with movement 8/10

P2: P3: Right neck pain: Constant deep ache 6/10 Right medial scapula pain: Constant deep ache 4-5/10

Body Chart

X X X X X X X X X X X

Relationship of Areas: Worst= P1. P1  P2  P3 Denies numbness and tingling

X X

History of Current Episode

• • Duration of symptoms: 10 days Mechanism of onset: While on vacation in Hawaii, he was rolled by a wave and hit bottom in a curled position. Neck as stiff and sore immediately and by the next morning, he developed the pain in the anterior shoulder and right scapula. He was able to rest and control activity. When he retuned home he resumed normal weight lifting routine. His shoulder started crunching and cracking, just like it did when he had a previous labral tear. Shoulder neck and scapular pain began to increase when he woke the next morning. • • • Progression of symptoms since onset: All areas are becoming slowly worse. Current status (improving, static, worsening): Worsening Treatment and response: NSAIDS , subacromial injection by MD 3 days ago no help.

Previous History

• Previous Episodes: Intermittent stiffness in his neck after heavy lifting or physical interventions on the job, goes away within 1-2 days. Had labral tear 2 years ago related to a forward slide while playing softball. Had surgery and has had no difficulty ever since. • Contributing Factors: None • Previous Treatment: Shoulder surgery on right arm two years ago.

• Medical History/Co-morbidities: None

Aggravating/Easing Factors

Area Aggravating Activity

P1 Right shoulder ** Reaching overhead Lifting more than 5 lbs. Unable to lie on the arm P2 Right neck Reaching overhead Looking up

Time /Pain Level Eases

8/10 7/10 Out of positions, arm **resting on top of head Out of position

Time to subside

10 minutes 5 minutes P3 Scapular pain Increases after P1 and P2 6/10 Out of position 5 minutes

24 Hour Behavior

• Night: All areas ache, has difficult time finding comfortable position in which to rest shoulder. Has spent the last two nights in recliner. • A.M.: Better if he can find a comfortable position for the arm.

• Day: Varies with use, generally worse by end of day

.

Red Flag Screen: Negative

• • • • • • • General Health: Excellent Age 55 with history of cancer: Negative Cord: Clumsiness in hands, disturbance of gait suggestive of spasticity: Negative Cauda Equina: Negative Steroids or anticoagulants: Negative Numbness and tingling in the hands and feet: Negative 5 D’s (dizziness, diploplia, dysphagia, dysarthria, drop attacks): Negative

Yellow Flag Screen

• • • • FABQ Score: Negative Depression Inventory: Negative Behaviors suggestive if depression: Negative – Use of extended rest – – – – Preference for passive treatment Withdrawal from daily activities Reports of extremely high pain Excessive reliance on aids or appliance – Self Medication I do have some concern about his total commitment to the “torn labrum diagnosis”

From the Body Chart: Structures to be Examined

Area

P1: Anterior shoulder

Structures Under the Area of Symptoms

Subacromial impingement Labral tear, anterior instability Biceps tendinopathy P2: Right neck P3: Medial scapula Cervical facets Cervical discogenic Muscles: Trap, levator Muscle Thoracic intervertebral joint Thoracic costovertebral joint Intercostal

Structures Which Refer Into the area of Symptoms

Cervical Spine Cervical radiculopathy Visceral referral: Liver, lung Visceral referral: Liver, lung Cloward’s point, cervical discogenic Gall bladder (too high) Other structures which must be ruled out First rib (CRLF) Clinical Pattern/Classification Cervical discogenic , cervical radiculopathy (Wainner TIC)

Boissonnault

Current Hypotheses: In order of priority

Hypothesis

Cervical discogenic Cervical radiculopathy Shoulder problem: labral tear or anterior instability, subacromial impingement

Supporting Evidence

Cloward’s point Mechanism of injury included forced flexion to spine Cervical rotation increases scapular pain Position of ease with arm on top of head. Worst area of symptoms are distal Inability to reach and lift overhead, inability to lie on the affected side .

Crepitus and clunking with movement

Evidence Not supporting

Inability to lie on the affected side is more consistent with shoulder Inability to lie on the affected side is more consistent with shoulder Ease with hand resting on head.

Presentation

Area

Severity Irritability Nature Stage Stability

P1: Anterior shoulder

Severe 8/10

P2: Right neck

Moderately severe 7/10 Moderate (15 minutes to settle) Moderate Cervical discogenic =/- radiculopathy Acute Worsening

P3: Medial Scapula

Moderate 6/10 Moderate

Plan of the Objective Examination

• • • • • Does the nature of the condition or presence of co-morbidities indicate caution?” Yes cervical discogenic with potential radiculopathy, at times severe, moderately irritable Will you limit the amount of examination? Yes Will you limit the vigor? : – Examine to P1: Yes – – Examine to limit of active range: No Add overpressure: No – Use repeated movements: Only repeated dorsal glide as potential centralizing technique – Use sustained overpressure, combined movements : No Are special tests indicated? – Neurological – Wainner TIC – Upper limb tension test – First rib What structures will you examine on day 1? Cervical spine, screen shoulder

Plan of the Objective Examination

• • • • • Do you expect the comparable sign to be easy or hard to find? Easy Why? – Patient report shoulder flexion to reproduce shoulder pain, rotation right to reproduce neck pain. I do not plan to increase vigor to reproduce scapular pain at this time. What test or movement do you think will reproduce the comparable sign?

– Shoulder flexion to reproduce shoulder pain, rotation right to reproduce neck pain. I do not plan to increase vigor to reproduce scapular pain at this time. Are there contributing factors which must be examined? – Shoulder stability, scapular kinematics What areas/structures must be cleared (ruled out as contributing factors)?

– Visceral disease unlikely given negative history and excellent health.

Objective Examination

• • • Observation – Affect: Clearly uncomfortable and anxious , protective of shoulder – Fitness: Appears fit Posture – Habitual: Sits fully flexed – Spinal curvature: Forward head,, slight loss of cervical lordosis – Signs of muscle imbalance: scapulae protracted , appears tight in pectorals right trap and right levator. Functional Screens – Hand behind head: unable due to shoulder pain

Neurological Examination

• • • • • • Reflex: – symmetrical 2+ biceps, brachioradialis, triceps, FDP – LE 2+ Dermatome: Sensation in tact Myotome: WNL : Shoulder pain with external rotation and biceps Hoffman’s: Negative Upper cervical ligamentous stability – Tectoral Membrane: Negative – – Transverse: Negative Alar: Negative Cervical Artery Screen: Negative through active movements

Active Range of Motion Cervical

Flexion Extension Rotation left Rotation right Lateral flexion left Lateral flexion right Retraction (dorsal glide)

Range

60 degrees 45 degrees 50 degrees 40 degrees 30 degrees 20 degrees 50 %

Deviation

Slight left

Symptoms

Comparable right neck pain Comparable right neck pain

Limit of Range

Pain Pain Moves poorly LC Right neck, shoulder and scapular pain Pulling right neck Neck and shoulder pain Pain Stiff repeated, eases scapular pain. Stiff

Flexion External rotation Abduction: Hawkins Kennedy Resisted external rotation Stability test

Active Range of Motion Shoulder

160 degrees 75 degrees (HBS) 160 degrees Full

Range Deviation

into slight abduction

Symptoms

Shoulder pain, with arc from 120 tgo end increase, increase neck pain Slight pull anterior shoulder pain at end of range Negative Pain End of range Pain

Limit of Range

End of range 4/5 Sulcus: negative Multidirectional: Slight increase Shoulder pain No pain End of range

Other tests

Test

Spurling’s Traction ULTT (upper limb tension test)

Symptoms Provoked

Compression not added

Positive?/Comparable?

Lateral flexion is comparable and condition judge irritable at this point. Positive Eases neck an scapular pain + 90 degrees of abduction and Positive by symptom reproduction and asymmetry CRLF (cervical rotation lateral flexion ) Deferred

Assessment Following the Objective: Review and re-rank your hypotheses

Hypothesis

Cervical radiculopathy Cervical discogenic

Supporting Evidence

Wainner TIC 4/4 LR>30 Cervical rotation increases scapular pain Eases with dorsal glide and traction, both signs of centralization

Question/Uncertainty

Nil Shoulder problem: • labral tear or anterior instability, • subacromial impingement Not tested at this point Painful arc in flexion, pain slight weakness with subacromial impingement Is a clinical syndrome apparent: Cervical radiculopathy Classification: Neck pain Centralization

Wainner et al. 2003

• Blinded, prospective diagnostic test study ( 82 patients) to assess the reliability and accuracy of individual clinical examination items and self report instruments for the clinical diagnosis of cervical radiculopathy • Findings – 34 items had reliability coefficients of at least fair or better. – 13 items had LR above 2 or below .50

– Single test item (TIC)cluster of 4 variables was identified and produced a LR estimate of 30.3

– 95% confidence intervals were wide.

• Conclusions: – Many items of clinical examination were found to be reliable and to have acceptable diagnostic properties, but the test item cluster was more useful than any single test item.

• ULTT A was most useful for ruling out cervical radiculopathy • Further investigation is required to validate the test item cluster • 11 variables with acceptable diagnostic accuracy

Test Reference standard: EMG Diagnostic Test Item Cluster (TIC)  ULTA A  involved cervical rotation < 60 degrees  + distraction test  Spurling A ULTT A Cervical rotation to the involved side ,< 60  Cervical flexion < 55  Biceps reflex decreased Distraction test Area of symptoms: scapula, shoulder Valsava Spurling test A Shoulder abduction test (hand on top head) Symptoms improve related to neck position Sensation in C5 dermatome.

Likelihood ratio 2 + tests .88 3+ tests 6.1

4+ tests 30.3

1.3

1.8

1.5

4.9

4.4

2.3

3.5

3.5

2.1

2.23

2.1

Post Test 21% 65% 90% Sn r/i .39

.39

.24

Sp r/o .56

.94

.99

.97

.89

.89

.24

.44

.38

.22

.5

.17

.65

.29

.22

.49

.41

.95

.90

.84

.94

.86

.92

.71

.86

C5 C6 C7 T1 T2 T4T5 Rib 1

Palpation Findings: PAIVMS

Range

CPA and UPA< 50% CPA and UPA <75% CPA and UPA< 50% UPA

End Feel

Stiff Stiff boggy Stiff, boggy Stiff, thick UPA Stiff and thick Hard and blocked Hard

Symptoms

Neck pain Sharp neck pain ** P=R Neck pain Local pain Local pain Local pain “Tight”

Reason for stop

P=R P=R Stiffness Stiffness Stiffness > pain Stiffness without pain

Reassessment following Palpation

Subjective Reassessment

Pain levels: P1: anterior shoulder 5/10 P2: right neck 4/10 P3: scapula 2/10

Objective Reassessment:

• Shoulder flexion 140 degrees before onset of pain • • • Lateral flexion right 30 degrees neck pain only Rotation right 55 degrees neck pain only Dorsal glide range increased

Assessment Following the Objective: Review and re-rank your hypotheses Hypothesis Supporting Evidence Question/ Uncertainty

Cervical radiculopathy Wainner TIC 4/4 LR>30 C6C7 Cervical discogenic Cervical rotation increases scapular pain Eases with dorsal glide and traction, both signs of centralization • Shoulder problem: • labral tear or anterior instability, subacromial impingement Not tested at this point Painful arc in flexion, pain slight weakness with subacromial impingement Is a clinical syndrome apparent: Cervical radiculopathy Classification: Neck pain Centralization Is a clinical syndrome apparent: Classification: • • Associated factors which will require treatment: Associated factors which will require treatment: Stiff CT junction T5T6

Select Subjection and Objective Asterisks

Area

P1: Anterior shoulder pain

Subjective /Functional Asterisks

Reaching overhead Lifting more than 5 lbs. Unable to lie on the arm P2: Right neck pain P3: Right scapula pain Associated Associated Associated Reaching overhead Looking up Increases after P1 and P2 • • •

Objective Asterisks

• Shoulder flexion 140 degrees • • before onset of pain ULTT Resisted external rotation • • • Lateral flexion right 30 degrees neck pain only • Rotation right 55 degrees neck pain only Extension 45 degrees Dorsal glide range 50% Mid thoracic pain + stiff Stiffness C7 –T2 First Rib Stiff

Treatment Day 1 : Intervention 1

Technique/Intervention: Manual traction C5C6 C6DC7 Intention of Technique :Centralize scapular pain and possible shoulder

Reassess Subjective /Functional Asterisks P2 Right neck pain 3/10

Patient /tissue response during performance of technique: “Feels good” Reports progressive decrease and relief of scapular pain and neck pain

Reassess Objective Asterisks P1 Shoulder pain decreased 5/10 to 3/10 Shoulder flexion 160 degrees before pain External rotation 4/5 with less pain Rotation right: increased 45 to 55 deg. Lateral flexion right : increased 40-40 deg Extension increased 55-65 degrees P3 Scapula pain 2/10 Exercise to support intervention: Repeated dorsal glide Trial of exercise: Dorsal glide 2 x 10: Result: No pain, full range, extension increased to 70 degrees without pain. Patient Education/Instruction: Home exercise program along with postural program and avoidance of sustained flexion activity/ and to follow with exercise

Treatment Day 1 : Intervention 2

Technique/Intervention: CPA and UPA C5-C7 IV- progressing to IV Intention of Technique :Reduce neck and shoulder pain and increase motion Patient /tissue response during performance of technique: Stiff, with pain at outset which decreases as resistance decreases

Reassess Subjective /Functional Asterisks P1 Shoulder pain decreased 3/10 to 1/10 P2 Right neck pain 0/10 P3 Scapula pain 0/10 Reassess Objective Asterisks Shoulder flexion 175 degrees, slight pain o/p External rotation 5/5 painless ULTT: ER – 45 degrees Rotation right: 80 degrees slight pain o/p Lateral flexion right : increased 60 deg Extension increased 65 - 75 degrees slight stiff with o/p Dorsal glide full range and painless Able to extend from this position Exercise to support intervention: None added here Patient Education/Instruction

Treatment Day 1 : Intervention 3

Technique/Intervention: Thoracic V Sitting T4T6 Intention of Technique :Reduce neck pain Patient /tissue response during performance of technique: No pain, good movement with cavitations/Feels much looser

Reassess Subjective /Functional Asterisks P1 Shoulder pain decreased 2/10 P2 Right neck pain 0/10 Reassess Objective Asterisks Shoulder flexion 175 degrees, slight pain o/p External rotation 5/5 painless ULTT: ER – 45 degrees Rotation right: 85 degrees slight stiff o/p Lateral flexion right : increased 60 deg Extension increased 75 degrees slight stiff with 0/p CRLF for first rib positive Exercise to support intervention: Seated thoracic extension over edge of chair to maintain gains in range. Patient Education/Instruction: Perform dorsal glides and seated extension 3very 2 hours

Treatment Day 1 : Intervention 4

Technique/Intervention: Seated V first rib Intention of Technique : Improve mobility first rib, assess effect on ULTT Patient /tissue response during performance of technique: No pain, good movement with cavitations/Feels much looser

Reassess Subjective /Functional Asterisks P1 Shoulder pain decreased 2/10 P2 Right neck pain 0/10 Reassess Objective Asterisks Shoulder flexion 175 degrees, slight pain o/p External rotation 5/5 painless ULTT: full range Rotation right: 85 degrees no stiffness with o/p Lateral flexion right : increased 65 deg Extension increased 75 degrees no stiffness CRLF for first rib full range Exercise to support intervention: No further exercise added Patient Education/Instruction: Perform dorsal glides and seated extension 3very 2 hours

Treatment Day 1 : Intervention 5

Technique/Intervention: Prone V lateral flexion C7T1 Intention: Improve cervical thoracic mobility Patient /tissue response during performance of technique: No pain, good movement with cavitations/Feels “fantastic”

Reassess Subjective /Functional Asterisks P1 Shoulder pain decreased 0-1/10 , “barely aware” P2 Right neck pain 0/10 Reassess Objective Asterisks Shoulder flexion 175 degrees without o/p External rotation 5/5 painless ULTT: full range Rotation right: 85 degrees no stiffness with o/p Lateral flexion right : increased 70 degrees Extension increased 75 degrees no stiffness CRLF for first rib full range Exercise to support intervention: No further exercise added Patient Education/Instruction: Perform dorsal glides and seated extension 3very 2 hours. No weight lifting at the present time.

Assessment Following the Treatment: 1)Review and re-rank your hypotheses 2) What is the impact of treatment on the working hypothesis Hypothesis

Cervical radiculopathy Cervical discogenic

Supporting Evidence

Wainner TIC 4/4 LR>30 C6C7 Centralization with and abolished with traction, dorsal glides and PA’s Shoulder problem: • labral tear or anterior instability Not tested at this point, slight shoulder pain persists • subacromial impingement Not supported Shoulder signs resolved with treatment of the cervical spine.

Question/Uncertainty

None None

Assessment Following Treatment

• • • • • Working hypothesis: – – Cervical radiculopathy due to discogenic disturbance C6C7 Possible shoulder problem not ruled out. Consider patient perspective. Was you initial hypothesis confirmed, clarified, modified or rejected? Can the disorder be classified or is a clinical syndrome apparent?

Did your assessment of Presentation change?

– Severity: Yes , progressive decrease during treatment – Irritability: Yes , progressive decrease during treatment – – Nature : Confirmed with response to treatment Stage: No still acute – Stability: Improved rapidly, recurrence possible Did you accomplish what you wanted/needed to do in the first session??

– Yes, more than expected.

Prognosis

• • • • Expected level and rate of recovery: Positive response to initial treatment indicates potential for full recovery. Residual shoulder problem is not fully evaluated Time frame and number of visits: 4-6 over 4 weeks if only the neck is involved Factors which will promote or impede recovery: In spite of change in symptoms and signs patient remains concerned about labral tear and is insisting on MRO Likelihood of recurrence: Possible due to the discogenic nature of the problem

Plan for the next session

Examine/Clarify/Rule Out

Working Hypothesis Cervical radiculopathy Discogenic C6C7 Rule out Possible labral tear Plan for next treatment session if the patient returns: Better Worse Progress cervical and upper quarter strengthening Reassess compliance and repeat Contributing Factors Previous history Patient concer Unchanged Reassess compliance and repeat Follow up: Patient cancelled next appointment: Feeling much better, only slight shoulder pain. MRI scheduled.

Review of Medical Record: MRI negative