Joined: January 31, 2005
I'd like to post another case for everyone to look at and discuss. This is a pretty typical case of cervical pain most of us see pretty frequently. I wasn't getting anywhere with her using things I consider to be EBP (manual therapy, DNF strength) and I transitioned to other interventions (pain education, relaxation, and ideomotor movement) when the EBP stuff wasn't working. Feedback appreciated.
Case: 44 y.o female office worker with recurrent neck and trapezius area pain x3-4 years. Several MVCs in the past as well. No radiation or N&T, rare occipital HA. PMHx for glaucoma only. Not helped by NSAIDs and rest. Had 4 visits of chiropractic with manipulation and modalities without relief. Concerned about some "bone spurs my doctor says may have to get scraped out." Imaging: moderate global cervical spondylosis with some DDD at C5/6. Also has calcification of the ALL at C5/6.
Exam: Fwd shoulders Bilat, no significant forward head AROM limited by pain, ROM 35 Flex, 40 Ext, 30 B sidebend, 60 RRot, 55 LRot Neg Distraction, Neg compression, NL ULNT Median 1 Bilat without symptoms BUE MMT 5/5; very poor deep neck flexor activation, very shallow breathing manual exam: TTP without active TrPs in periscapular area, Tx hypomobility with pain, Cx hypomobility globally.
Treatment: Tried my standard: Cx mobilizations, some MET, DNF activation exercises, pain education and relaxation techniques. No change in ROM or pain levels. Does not tolerate positioning or setup for thoracic manipulation, so skipped that. We talked about relaxation, practiced deep breathing, and talked about ideomotor movement for pain relief. I also de-mystified her imaging findings (ignore them, they're unrelated to pain) as I spend all day doing with most spine patients. All this is pretty standard for me when treating a patient who presents this way.
While talking, I realized my next patient had no-showed, and I had some extra time. I stood behind while she was seated, lightly palpated her temples and spoke about characteristics of correction (warming, softening, easy active movement that is unforced). This is the Simple Contact type approach that Barrett Dorko advocates. Almost immediately, her head began to rotate actively toward the left, and I followed. I did not move her. She did several repetitions of flexion and roation on her own, and I just followed. After a few minutes, her flexion had improved to 50 degrees, L rotation 60, and R rotation 85! Left with a smile and much better motion.
Based on previous data about manual therapy, I can expect a good between-session improvement if there has been an intrasession improvement (Tuttle 2005). I look forward to seeing her again in a few weeks (her travel requirements).
I wanted to see what everyone thought about the clinical decisions and EBP type progression on this case. Open to questions. J
JS, upon seeing a pt similar to this, I find that simple soft tissue release techniques to temporalis, scalenes, DNFs including SCM and TALKING to the pt while doing so relaxes them tremendously. I agree with you about discussing imaging findings with respect that pts think that if it's on the film it is their primary problem.
An interesting example: the marketing Rep down the hall had a L4/5, L5/S1 herniation with radiculopathy and visible on MRI...4 months later MD took another MRI and the herniation was still there. MD could not understand why the pt was not in pain anymore. (He has been receiving therapy at another one of our clinics).
BTW, how was her state of mind? stressed out/any anxiety?
Hopefully she doesn't get into another accident while out of town:)