|
|
Stumped again
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Stumped again - January 26, 2007 2:08:00 AM
|
|
|
ALICIAPT13
Posts: 95
Joined: December 12, 2005
From: North Syracuse, NY
Status: offline
|
I have been seeing a patient who was referred to me for (R) shoulder tendinitis and (L) lateral epicondylitis. After examination I began treating the cervical spine as he had a lot of tenderness and some UE numbness. Another therapist worked with him while I was on vacation and discovered pain in the thoracic spine. Here are my current findings:
-The pt. is a custodian who had been wearing a backpack-like vacuum cleaner every day at work, which was significantly heavy.
-Insidious onset of (B) arm pain and numbness.
-Decreased AROM in (B) shoulders grossly, limited by pain.
-Decreased strength in (B) UE, including grip.
-Cervical AROM WNL
-Thoracic AROM WNL but painful
-+3 TTP thoracic spine, paraspinals, scapular region
-X-rays show arthritis in shoulder, no MRI
I have been treating him with myofascial release, gentle STM, gentle ther ex (B) UE and cervical/thoracic spines, AROM and PROM thoracic spine and (B) UE.
He on occasion feels slightly better, but overall notes no sgnificant improvement.
Any thoughts????
THANK YOU!
Alicia
|
|
|
|
|
Re: Stumped again - January 26, 2007 2:28:00 AM
|
|
|
USAPT
Posts: 278
Joined: January 14, 2004
Status: offline
|
Alicia, sounds like a fun one..
what about passive accessory motion (c/s, t/s)? provocation of pain or restrictions noted?
what were you results of the cervical eval?
how long has he had his pain?
what has been the MD rx thus far? meds, injections?
a few ?s, but we need more info. Thanks
-Jason
_____________________________
Jason, PT
|
|
|
|
|
Re: Stumped again - January 26, 2007 2:43:00 AM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
It sounds like you may be dealing with a backpack brachial plexopathy.....found in Military recruits and soldiers. I just reviewed an article from the British Journal of Sports Medicine regarding the condition on my site, and also put up the .pdf file on EvidenceInMotion as well.
The transient weakness may be leading to dysfunctional movement patterns, thus the cuff tendinitis/impingement, and perhaps the tennis elbow as well.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Stumped again - January 26, 2007 2:50:00 AM
|
|
|
ALICIAPT13
Posts: 95
Joined: December 12, 2005
From: North Syracuse, NY
Status: offline
|
Jason,
-I don't think I would be able to apply any pressure to his spine without him going through the roof. It's hard enough to keep him still for MFR.
-The cervical eval didn't reveal much besides tenderness. I was able to move him at each level, but as I touch him he c/o "pressure." Compression and distraction were negative. He does have positive NTT with the median nerve biased. When we tried doing a nerve stretch he c/o a severe flare-up for 3 days.
-His pain began November 1st of 2006.
-He has not had any injections from the MD and tries not to take pain meds because he doesn't like how they make him feel "loopy." At this point he is determined to get better with PT because the ortho is talking about surgery. On what? I don't know.
-He is also somewhat of a whiner, so it is hard for me to believe that his pain is as severe as he is making it out to be. There is also the issue of this being a worker's comp case, secondary gain, yadda yadda yadda... but I do believe that there is some impairment and this is not just a case of a malingerer.
Hope this sheds some light...
Alicia
|
|
|
|
|
Re: Stumped again - January 26, 2007 4:33:00 AM
|
|
|
ALICIAPT13
Posts: 95
Joined: December 12, 2005
From: North Syracuse, NY
Status: offline
|
John, is there anythig (realistically) I can do for this patient?
Thanks for the info
Alicia
|
|
|
|
|
Re: Stumped again - January 26, 2007 5:28:00 AM
|
|
|
Shill
Posts: 1107
Joined: February 13, 2003
From: Madison WI USA
Status: offline
|
Alicia,
If you want more opinions, in my experience, irritated nerves should be shortened, rather than stretched. If his neck eval is truly normal, including full range extension of the neck, in sitting and supine, complete with analysis of repeated sustained extension, I would, at a minimum, have him position himself frequently in passive scapular shrug positions, to "de-tension" the entire plexus. He has to truly rest from the aggravating tasks as well. His head is undoubtedly jutting forward while carrying this hulking sucker (pun intended) around on his back all night long, and the forward head position leads to even greater mechanical tissue strain. Id be exploring neck extension and plexus detensioning in every possible combination and position to get some symptom control.
One question comes to mind? What sort of surgery is being contemplated?
_____________________________
Steve Hill PT
|
|
|
|
|
Re: Stumped again - January 26, 2007 5:55:00 AM
|
|
|
USAPT
Posts: 278
Joined: January 14, 2004
Status: offline
|
Alicia,
Agree with above. I would attempt some strain-counter strain techniques (basically the de-tension) maneuvers. Depending on what side is most painful, palpate for tenderness, hold your palpation, passively position the cerv spine in positions so that the musculature is in a shortened state, and then hold for 90sec-->re-check. There should be some degree of 'tension' relief. Good luck
ps, take his pulse/resp rate before/during/after palpation and doc whether there is a difference. If he is that 'painful' his heart/respiration rate should increase.
_____________________________
Jason, PT
|
|
|
|
|
Re: Stumped again - January 26, 2007 6:49:00 AM
|
|
|
proud
Posts: 951
Joined: March 22, 2006
Status: offline
|
Just a couple of things to consider.
Accoring to the 4 test item cluster for cervical radiculopathy( Wainner et al 2003), have you added Spurlings A test and assessed for cervical rotation greater than 60 degrees to the ipsilateral side?( the other two being ULTT and distraction). According to this report, if 3/4 are positive you can be .94 specific with the dx of cervical radiculopathy....4/4 .99...2/4 .56...
Other than that I agree with John and shill...investigate brachial plexopathy.Taping to temporaily offload the neural structures could provide some useful information.
As well a trial of thoracic taping if this is neural tissue sensitization...from spinal extension to flexion, the spinal canal elongates approx 5-9cm( Breig 1978). Taping the T-spine will help the patient avoid excessive flexion. Just to see the effect to aid in dx.
And I would throw in the FABQ(w) as well by the sounds of things.
Good luck.
|
|
|
|
|
Re: Stumped again - January 26, 2007 7:01:00 AM
|
|
|
rwillcott
Posts: 455
Joined: March 20, 2006
From: Canada
Status: offline
|
I would have to agree with Duffy.
I would also recommend checking some of the the thoracic outlet tests as well such as Adson and Halstead tests.
Maybe some postural taping like proud recommended along with some gentle stretching of his scalenes, pec minor and also check his first rib for stiffness.
Rob
|
|
|
|
|
Re: Stumped again - January 26, 2007 12:19:00 PM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Alicia: Not much one can do with regards to the nervous system, as the damage or trauma has already occurred. Of course, eliminate the continuation of external trauma, both work wise, and even body weight wise (thus the taping suggestions which are so very appropriate)
Strengthening is next. This does not need to be bodybuilding, but rather simple isometrics to facilitate those weird neural pathways that we don't understand very well. Exercising the muscle groups involved with a certain nerve root or plexus branch can have great results with pain reduction, restoration of normal movement patterns, and of course improved function.
John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Stumped again - January 26, 2007 2:43:00 PM
|
|
|
matotoms
Posts: 57
Joined: February 16, 2005
From: nbn
Status: offline
|
i will bet anyone here right now 500 dollars this is malingering and I dont have to ask any questions or exam the patient.
get him an EMG, record the negative findings and discharge.
|
|
|
|
|
Re: Stumped again - January 29, 2007 5:16:00 AM
|
|
|
ALICIAPT13
Posts: 95
Joined: December 12, 2005
From: North Syracuse, NY
Status: offline
|
MT - How can you be so quick to judge?
Over two months the sxs have been so consistent. The worst tender points occur around T7 bilaterally. Do you think he is able to discriminate that well each time I touch him to know that it's the same spot each time?
|
|
|
|
|
Re: Stumped again - January 29, 2007 1:42:00 PM
|
|
|
rwillcott
Posts: 455
Joined: March 20, 2006
From: Canada
Status: offline
|
mt is clearly disgruntled.
I wouldn't pay any attention Alicia. Sounds like your doing a fine job!
Rob
|
|
|
|
|
Re: Stumped again - January 29, 2007 2:17:00 PM
|
|
|
SJBird55
Posts: 2467
Joined: May 10, 2004
From: Michigan
Status: offline
|
Can I ask a really stupid question? Why does he have to carry a backpack vacuum? Why don't you start off there and see what could be altered - can the thing be put on wheels - like a golf bag cart thing? or like a shop vac on wheels? Could something be designed so he just wheels it behind him? I'm not sure if he is working now or not, but if he returns to work and is put right back into the same situation, I'd be willing to bet he's going to have issues.
Psychosocial: Also, dig in a bit with what was going on with work... how long was he there? Does he like his job? What about the people that he works with - what's his relationship like with them and with his supervisor?
On a slightly different view: What is his age? How heavy was heavy for the vacuum? If he's been off work the whole time and you haven't made huge gains (it sounds like you've been addressing the cervical spine) and the pain is always at the same T level... I don't know the sensitivity or the specificity of this, but how does he respond to a tuning fork in that area? How sensitive is the area to that? Or what if you thump him on say the spinous process or something a few levels above or a few levels below - does he have pain at the area he normally hurts (in other words not at the level you thumped)? (Thump probably isn't a very good word, umm... percuss isn't the right word either... hmmm... how sensitive is the level that normally hurts to vibration a few levels above or a few levels below?) Has he been on steroids? What could be the potential for a thoracic compression fracture? A bone scan could be done...
|
|
|
|
|
Re: Stumped again - January 29, 2007 4:00:00 PM
|
|
|
matotoms
Posts: 57
Joined: February 16, 2005
From: nbn
Status: offline
|
[QUOTE]MT - How can you be so quick to judge? [/QUOTE]same way other people can throw out diagnoses and interventions without seeing him..... based on experience.
[QUOTE]He on occasion feels slightly better, but overall notes no sgnificant improvement.[/QUOTE] [QUOTE]Over two months the sxs have been so consistent[/QUOTE]why keep on seeing him? 2 months no progress? should have D/Cd 4 - 6 weeks ago. thats not disgruntlement, thats proper practice. Maybe he has a tumor, or something real going on, tho it is doubtful, why has the doc not done more diagnostics.
Im not knocking you at all, sounds like a sound treatment plan, but it is not working. physical Therapy is not always what is needed to get 'better'.
Insidious onset, bilateral symptoms, he obviously made a point of the new work equipment and its weight. nothing really objective..grip strength? thoracic ROM? cmon.
if he a neuropathy it should show on EMG. Recommend it and get back to us with the negative results.
|
|
|
|
|
Re: Stumped again - January 30, 2007 12:04:00 AM
|
|
|
SJBird55
Posts: 2467
Joined: May 10, 2004
From: Michigan
Status: offline
|
I am partial to mt's thoughts too - 2 months without consistent results sucks! If you aren't getting consistent results, well, there is something you are missing (T7 is too low to be giving the neuro symptoms, but I can't see his posturing) OR he's playing games.
|
|
|
|
|
Re: Stumped again - January 30, 2007 1:58:00 AM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Alicia: You did not post until later that this has been going on since November (not sure if you have been treating since November). I concur with the others that EMG needs done, as that will help identify if this guy is legit or a slug
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Stumped again - January 30, 2007 2:40:00 AM
|
|
|
ALICIAPT13
Posts: 95
Joined: December 12, 2005
From: North Syracuse, NY
Status: offline
|
I have been treating him for a total of 5 weeks at 3x/wk. Follow-up visits were canceled by the referring MD. The one appointment he went to with the worker's comp. doctor he was told he had (B) UE tendinitis that may be coming from his neck and was referred to a pain management MD. The pain management guy, also an ortho, says surgery will be necessary. No further diagnostics have been done and the patient was not told what type of surgery the ortho wants to do, but has been scared away by the idea of "spine surgery." He wishes to continue PT, a does the referring MD, even though the progress report was more than clear about his lack of progress. He was told he was going to have an EMG, but that won't be set up until he sees the referring MD again.
As for the backpack at work, he states that there is no other way the job can be performed and he must be in "top physical condition" to keep his job. He has been OOW since 11/01/06.
|
|
|
|
|
Re: Stumped again - January 30, 2007 6:14:00 AM
|
|
|
matotoms
Posts: 57
Joined: February 16, 2005
From: nbn
Status: offline
|
the guy has had xrays and no MRI CT scan and has been told he needs sx. that is the doctors way of saying...there is not a **** the wrong with you and i am going to try to scare you into getting better by threatening to hack into your spine and im not going to keep giving you these pain narcotics, but if ya want to go get a back rub 3 x a week go ahead.... GTF out of my office.
either that or the guy is lying about the Sx just like he is lying about not liking the pain meds. who the hell doesnt like pain meds? especially if you are not working.
look he is malingering, if you can stand spending 30-60 mins with him, keep treating him till the ins runs out...you can almost 'justify it' if you are creative enuff. if he is a drain on your psyche you have every right to D/C at least 'hold until the EMG results are in', which is basically your way of saying ......GTF out of my office.
sorry for the realism, im just disgruntled b/c im out of pain meds.
|
|
|
|
|
Re: Stumped again - January 30, 2007 7:44:00 AM
|
|
|
drbuddy
Posts: 429
Joined: July 30, 2005
From: Pennsylvania
Status: offline
|
THe MD said he had "(B) UE tendinitis"? I love the crap they come up with...
Try more aggressive STM...whether he squirms or not.
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
 Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.094
|
Printable Version
All Forums >> [RehabEdge Forum] >> Open Forum >> Stumped again 
