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Re: Cervical Nightmare!
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Re: Cervical Nightmare! - April 29, 2005 10:13:00 PM
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Synergy
Posts: 592
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From: Texas
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Shill,
I'm not familiar with DISH, but rigidity is definitely there. When I get back to the clinic next week, I'll look into his films again.
Sarah,
We've been working on his deep neck flexors and today he did make some progress with them. I haven't attempted 'Simple Contact' because I don't know the technique (maybe I need to go to Barrett's course).
Rick,
I was referring to his entire c-spine joint mobility. I don't think this poor gentleman has joints of Luschka (sp?). I am almost certain that I'm dealing with bony restriction as opposed to soft tissue/muscle guarding. I started him on a UBE to help with the 'vascular type exercise' and he had no increased c/o pain. The referral is from a GP.
Erica,
Pardon my initial introduction of this patient. I was trying to convey my subtle fear of working with this guy's neck as I have yet to work with a patient that was this 'stuck'. I actually have been performing some NAGS (last two visits) into flexion and he did show some gross improvement with ROM. I also stripped away the strengthening portion of his protocol.
Thanks for your replies everyone. I instructed him in performing self-SNAGs with a towel/pillow case for over the weekend. I struggle with teaching patients how to 'move' on their own, as Nari suggests. I know I need quite a bit more practice and maybe a visual to help me with this.
Anyways, I'll keep you posted. :)
_____________________________
Chris Adams, PT, MPT
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Re: Cervical Nightmare! - May 2, 2005 9:28:00 AM
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jbeneciuk
Posts: 112
Joined: November 26, 2004
From: Jacksonville, FL
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Chris:
could you ellaborate on "bony restriction"...and how you came to this theory ?
Also, referring to this gentleman "not having any joints of Von Lushka"....where did this assumption come from ??
JBeneciuk
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Re: Cervical Nightmare! - May 2, 2005 1:05:00 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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why do I always have to be the bad guy? I haven't responded thus far, b/c no matter what i said it was going to come off wrong, but really I just want to point you elsewhere. i think this is a normal reaction for someone not used to proper mechanics and assessment of C-spine. Please do not be offended, be enlightened. You have a lot to learn as do I and all of us about C-spine. Look at this guy's presentation and in the future remember it and see if you'd do anything differently. A therapist who treats patients the same method each time is not dynamic and fluid enough to keep up with the times, you should always be changing based on experience in education. I mean who really cares about ROM, give me statements about quality of movement, is it joint, is it muscle is it etc...I used to actually measure people's finger tips to floor for sidebending measurements of L-spine..sure it was objective but did it really tell me anything? Did it tell me what was sidebending, where was motion occuring and not occuring, etc?
My first clinical instructor said Ben "you cannot make chicken salad out of chicken sh%t. Well, to a degree I always remember that, not everyone coming in with dysfunctions can be brought to a state of full mopbility and running marathons and throwing kegs again. Sometimes people just need reassurance and explanation of their dyfunction and ot education, not everyone "needs to be fixed". If this guy is that bad off, then refocus your treatment plan. I do not feel a need to take someone with no mobility and who has not moved their head in 4 years and get them full mobility. Maybe the muscles are guarding to protect an instable spine? Maybe they are protecting the spurs from pinching the nerves. More mobility doesn't always mean better results.
Try getting in their and finding how each segment feels, where motion is occuring, where it is not occuring, where it is being compensated for, where is it being guarded from going, etc. ROM means nothing to me except on some distal parts, even then, I'd like ot know how and why the ROM stopped, was it guarding how much further could you bring it, etc. the r1, r2 kind of discussion. MAybe this should alert you that you need more courses on assessing the c-spine and t-spine. Don't get me wrong, I think it is great that you are on here reaching out, and I too used to think of some of my C-spine pts as c-spine nightmares, or the chicken sh%t theory, but you cannot win them all, give the guy some good ideas about how to avoid flare ups etc, and send him on his way.
I guess if I continue I'll either come across as belittling or rambling, so I'll stop, but my gist is this:
Not every dysfunction needs to be treated, not every dysfunction is a bad thing, it may be occuring for a reason (flexed posture in a person with severe stenosis...no need in straightening them up, etc...)not every patient is a suitable candidate for days and weeks of therapy, some patients are too far gone to see good gains with therapy interventions, focus your attention of education, etc. Ok I have begun rambled..I am out-
Ben Galin, MPT, OCS
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Re: Cervical Nightmare! - May 2, 2005 3:12:00 PM
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Synergy
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From: Texas
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JBeneciuk,
Bony restriction = segmental hypomoblity unrelated to muscular spasm. I wasn't necessarily assuming anything. About the joints of Lushka...disregard that statement. :) Too much alcohol when I originally typed this message.
Ben,
Thanks for being the 'bad guy' and belittling me to the point of self-destruction. :) Honestly, thanks for the comments. I don't think it's a matter of 'someone not being used to proper mechanics and assessment of the c-spine'. I was just trying to impart that this was the 1st neck that I've seen like this and I know there will be many more to come. I'm comfortable with my assessment but I'm not naive enough to think I don't need more knowledge.
I agree with you in regards to quality of movement versus specific ROM measurements as a gain in ROM, in my opinion, must be a gain in quality of movement first and foremost. Again, I appreciate your 'rambling' and I sure as heck don't mind it at all...as long as it's constructive. :)
The Pt. in question returned today with a maximum pain rating over the weekend of 1-2/10. His ROM was improved at least 40-50% in each direction, the most notable being flexion. He said he was able to turn to rotate his neck better while driving and didn't find himself rotating his neck and shoulders as one 'functional unit'. However, his quality of movement, especially with side bending, is still poor -> fair.
At the end of his session, he said he felt great and more mobile. Something is working so I'll continue to modify as I see fit. :)
_____________________________
Chris Adams, PT, MPT
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Re: Cervical Nightmare! - May 2, 2005 3:32:00 PM
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srcase
Posts: 551
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From: Michigan
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Chris,
That's great news! See, you shouldn't doubt yourself so much. We all need a little reassurance sometimes that we are on the right track though.....
Sarah
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Re: Cervical Nightmare! - May 2, 2005 5:54:00 PM
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Synergy
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From: Texas
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I forgot to add one more thing...something I thought was pretty funny.
Like most (hopefully all) PTs and physios alike, we like to see functional improvements in our patients. When this Pt. came in today, we were discussing his weekend and that was when he told me he thought as if his mobility had improved since last Friday. I asked him how he thought he had improved...specifically what task were you performing when you noticed it.
ROFL...he said he was able to drink his DrPepper more easily by having increased cervical extension and not having to extend his entire spine to get the last few drops of nectar. :)
That made my day!
_____________________________
Chris Adams, PT, MPT
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Re: Cervical Nightmare! - May 2, 2005 9:19:00 PM
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nari
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Chris
Good work! And it goes to show, that, as Ben said, ROM is not important to the patient really, it is function that counts. That is what the patients want - whereas we tend to get locked into ROM in lieu of function. Both parties have different ways of measuring outcomes.
I wonder if drinking Dr pepper should be added to the functional outcomes - eg Quebec - ? ;)
nari
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Re: Cervical Nightmare! - May 3, 2005 8:10:00 AM
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JLS_PT_OCS
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Ben-
Perhaps Chris is not experienced enough to come to his own defense, so I will.
What are "proper" assessements and mechanics of the C-spine? Actually, throw out mechanics, just focus on the "proper assessment". Do you mean if I'm not looking at what you're looking at then I'm wrong?
How do you determine where the motion is coming from? How do you know you're right?
How do you determine quality of movement?
What does segmental mobility have to do with function or pain? There is at least some evidence to suggest they are entirely unrelated.
How do you know if a restriction is "joint or muscle"? If you are using end-feels such as "R1" and "R2" for this, what is the validity/reliability of these subjective measurements? Would it surprise you to hear that it is very poor?
Surely you are not taking young Chris to task for failing to use unsubstantiated and subjective evaluation methods, and to base his treatment on such findings?
When you suggest further "courses" for Chris, I'm sure you are well aware of the glut of CEU offerings that are not based in evidence, or strictly teaching someone's pet theories or techniques and passing them off as effective. Surely this is not the kind of training you recommend?
I think many of us agree that ROM measures are not perfect and that not every dysfunction needs to be treated. But let's not pretend that certain evaluation methods have more merit than others, as I do not believe there is sufficient evidence to make that claim.
Chris has received advice here consistent with the evidence for effectiveness (active motion, mobilization). I'm pretty sure I know why you consider your response to be making you the "bad guy", but what I'm not sure of is whether you are giving him advice that has value or merely telling him he needs to do things the way you do them.
What do you think?
Perhaps I'm the bad guy now?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Cervical Nightmare! - May 3, 2005 8:50:00 AM
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FLAOrthoPT
Posts: 1011
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From: West Palm Beach
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yes
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Re: Cervical Nightmare! - May 3, 2005 2:17:00 PM
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dosrinc
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From: Bonita Springs
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Chris-
Great to hear about the improvements and like the info about the Dr. Pepper!
Now my question to you is this, did you restore joint mobility to a neck whose joints were "Like Friggin Concrete" in such short a time frame or did you simply teach him through your words and techniques that it was OK to move, reduce the pain induced gaurding and in that way restore his functional mobility?
What is your perception of why he can move now when he was unable to a couple of visits ago?
By the way, I appreciate that you are concerned enough about your patient's well being that you would risk subjecting yourself to rapproach on this public forum. There are far to many passive, apathetic PT's out there. Keep the cases coming, they stimulate critical thinking and that is never a bad thing.
Rick
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Re: Cervical Nightmare! - May 3, 2005 3:21:00 PM
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Synergy
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From: Texas
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Again, thanks for the comments!
Jason,
[QUOTE]Perhaps Chris is not experienced enough to come to his own defense, so I will.[/QUOTE]Okay I admit it...I'm a complete pansy ass!
Rick,
To answer your first question, a bit of both. I worked with him Monday for about 30 minutes trying to 'teach' him that he can move his neck a given direction. I also spent a majority of the time mobilizing his c-spine along with active movement ala Mulligan. I threw in some STM/MFR as well. At the end of the session, the guy just moved better...bottom line.
My perception on why he can move better now compared to last week is that I've limited his exercises when he comes in (specifically the strengthening ones...tossed them out completely for the time being) and began a more intensive manual approach. I sat him down, watched him move, and began 'correcting' or 'modifying' his poor movement patterns.
I monitored each segment (mainly cervical and upper thoracic) with active motion and found several restrictions in most all planes. The past two times he's come to rehab, I've performed the above activities with him, along with some AROM exercise and UBE to help with mobility/oxygen perfusion.
I think Jason hit the nail on the head with 'young Chris'. I realize that I am a rookie, but that's not going to keep from coming to this more than informative forum/discussion board. Hell, I've gotten more help here than I have elsewhere. Rick, I am concerned with my patients and don't worry...I'll be bringing a plethora of questions to you guys whenever I feel the need to do so. I'm not concerned with what people think of my skill level when I post here and I have no problem reading a reply to my post that may be 'belittling'. If these are things to push me to strive to be a better clinician, then so be it...and by all means, keep it coming. :)
*Whew*
Thanks!
_____________________________
Chris Adams, PT, MPT
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Re: Cervical Nightmare! - May 3, 2005 5:48:00 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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i'd hug you if i were there
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Re: Cervical Nightmare! - May 3, 2005 6:11:00 PM
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jbeneciuk
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From: Jacksonville, FL
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Chris:
I've enjoyed reading this discussion...just a bit of my experience...I've been practicing for about 2.5 years, and in my experience I've discovered that a sound mentor is just as good as any CEU course you can take...most of us "newcomers" do not get the chance to work with a quality mentor and this is something that we should all take advantage of...or seek to work with one even on a weekly or bi-weekly basis (journal clubs, mock patient evaluations, etc)...since I have been taking part in this I feel my knowledge base has improved greatly...I know he is probably feeling all good about himself now, because he is a member here...so before he starts getting all teary-eyed...I will end this reply !!
Good topic though Chris
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Re: Cervical Nightmare! - May 3, 2005 7:21:00 PM
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Synergy
Posts: 592
Joined: March 11, 2004
From: Texas
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Ben,
I think Chris Farly said it well "Brothers don't shake hands, brothers hug." :) BTW, what did you think about the Heat's rout of the Nets? I'm pulling for a Miami vs. Dallas championship, with the victor being the Mavs of course. :)
Jbeneciuk,
I echo your thoughts exactly! I don't have the advantage of having a physical 'mentor' at work as I am the lone PT. My boss, a PT of 5-6 years, runs the 'business' side while I perform the patient care. My friends told me from the beginning not to take the position because of that reason alone. However, I've received quite a bit of 'mentoring' here and I'm hungry for more.
_____________________________
Chris Adams, PT, MPT
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Re: Cervical Nightmare! - May 4, 2005 2:41:00 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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I was fortunate enough to have me and 2 other OCS and manually trained PTs at my first job. Pay sucked, but the experience was amazing...I try to tell all new grads get a job working along side someone who is how you want to be, if you are in the middle of a lot of part timers or per diem, or PTs who are all excercise all ACL, etc, you'll never learn how to learn and know what to know etc. SO I agree finding a clinical mentor is key. I 2 years ago found a business PT mentor which helped almost as much as well. And I am a transplant, a new englander, so I root for all new england teams, and in nba i follow the UCONN players so right now that is seattle, detroit, chicago mainly. But I love watching the mavs, and all those other west coast teams, actually I really like most of the nba right now, just not the old bruiser teams like indiana or knicks or jazz....too slow of play for me...anyway gotta run-
Brn
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