This is a VERY powerful case report.  Read on to see how osteopractic intervention set the bar higher in physical therapy results.

Initial Evaluation

Subjective History: 42 y/o female presents with neck and arm pain.  It started when she was lifting heavy objects at work and at home due to circumstances of moving some things.  Her initial sensation was “her neck was caving in”.  She sought care from Dr. ***, who ordered MRI.  It showed herniations and then referred to PT for several weeks, then had 2 injections in neck— both helped some.  She was out of work for 6 weeks, but then returned to work and this aggravated her symptoms again resulting in another ESI in August and this helped for about 5 weeks too.  She also had a trigger point injection in upper trap after about 6 more weeks, but does not think that helped a whole lot.  She is returning to PT at this location as she still has headaches and (upper trap) pain that is constant, does not go away and is starting to change her as a person.

Date of Onset: 7 months ago.

Relieves symptoms: Nothing she can think of. She constantly is moving arm/shoulder. TENS unit helps while it is applied.

Location of Neck Pain: Initially, she had really intense headaches (that would reproduce with pressure points). However, the headaches are more subtle from occiput to frontal region L > R. Left side of neck around upper trapezius ridge.  She did have L UE symptoms but this improved after both ESI (it was described as burning, tingling, numbness). Pain is aggravated with the following activities or positions: Pretty much any activity, including housework, taking care of children, turning head both ways. Pain Quality: More achy and constant, as well as “knotted up”.

Pain Rating: 2/10 currently, 2/10 at best, 3/10 at worse ; but constant and never changes too much now.

Sleep Disturbance: Very difficult to lie on left side.  It wakes her 1-2x/night and now she sleeps on back or right side. She tried use of TR but started to irritate her.  She has a lordosis supported pillow, which seems to help.

Medication: Flexeril (takes at night for last 3 weeks & helps her sleep), constant use of ibuprofen (2 in morning and 2 in afternoon for past 2 weeks)

Cervical Active ROM
Cervical Extension AROM: 30 degrees

Cervical Flexion AROM: 50 degrees with pain at end-range

Cervical L. Lateral Flexion AROM: 25 degrees with pain at end-range

Cervical L. Rotation AROM: 80 degrees with pain at end-range

Cervical R. Lateral Flexion AROM: 25 degrees with pain at end-range

Cervical R. Rotation AROM: 80 degrees with pain at end-range

Neurological: 2+ B C5-C7. Negative Hoffman’s & Supinator Sign. Negative ULTT.

MMT: 5/5 all myotomes.

Palpatory findings: Hypomobilility through P/A and lateral glide testing of C0-1  & C1-2 on involved side (negative flexion-rotation test though).   Marked tenderness and familiar symptoms to ischaemic compression over mid-belly of upper trapezius, levator scapulae and scapula insertion at superior/medial border of levator scapulae.

Through speaking with patient about previous PT experience:

She received thoracic spine manipulation (mid-thoracic), cervical spine retraction, peri-scapula strengthening and cervical traction.

My treatment on 1st visit:

  1. Manual therapy
    • AA manipulation Bilaterally
    • Upper T/S “lift-off” Manipulation,
    • Mid-thoracic (T4-10) manipulation
  2. Exercise Prescription
    • Thoracic Spine Rotation in child’s pose position
    • Cervico-thoracic junction Extension over Foam Roll and Rolling Through T/S with Foam Roll

Immediate response at time of visit: 50% relief of all symptoms but still had pain at End-Range Cervical Rotation as described above.

Response in patient’s words at follow-up 2nd visit:

Patient reports she felt good after last visit.  However, yesterday her (upper trap) pain is back, and is the same.  However, no headaches.  The exercises give her relief, but only about 30 minutes.

My treatment on 2nd visit:

  1. Manual Therapy (Manipulation)
    • AA manipulation Bilaterally
    • Prone CTJ Manipulation Bilaterally
    • Mid-thoracic (T4-10) manipulation
  2. Dry Needling (could not perform on day 1 due to Virginia’s law of needing approval by physician)
    • Semi-standardized protocol for CGH per Dry Needling Institute
    • Additional point of levator scapula at insertion on scapula

Immediate response at time of visit in patient’s words:

I want to cry right now because I have not felt this good since my injury started

Response in patient’s words at follow-up visit:

I am doing fantastic.
That was the biggest relief I have had in 7 months.
It was the relief I have been looking for.
The exercises now are MORE effective and give her better relief at home.
For the first time this weekend, her husband and children told her that she didn’t complain about her neck/shoulder.

Take-home message from this case:

  • Firstly, the combination of manipulation and dry needling is powerful.  In this case, addition of dry needling at visit 2 resulted in marked improvements in headaches and localized upper trapezius symptoms.
  • Don’t just think that since symptoms are 7 months in duration that you can’t treat tissues locally and need some type of psychosocial component.  This individual was hurting and on her last leg. As noted in her expression at 3rd visit, her pain was affecting her relationship with her family. In this case, there was a constant barrage of C-fiber infiltration from the myogenic components of multiple muscles.  Stopping this can result in healing and change in pain.
  • I stated that standard PT had failed in the title.  Don’t get me wrong, it did help; but it was obvious for the patient that she needed something more.  It shows you that in the modern thought process of regional interdependence, we need to stay with our roots and treat locally too.  I would say go north (upper cervical spine) if typical treatments are not addressing this and you are not seeing results. Don’t lose sight of treating locally and thinking of just how the brain perceives input.
  • If you are a student or new therapist reading this, then if you run into a brick wall, go seek assistance from a mentor or someone with additional training.  See how they evaluate and treat an individual such as in this case.  Learn, reflect, and grow.
  • I also stated that medical management had failed too.  The ESI was the treatment that centralized upper extremity symptoms and obviously made an impact as we know the centralization phenomenon is prognostic.
  • The patient had a trigger point injection in the upper trapezius but no relief.  I wonder why? Was it because there was more involvement at the upper cervical spine and just treating the muscle did not help?  Or, was the levator scapula more of the pain generator?

What are you thoughts with this case?

 

 

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6 comments

  1. Dr. Vaughn,

    I appreciate your blog and enjoy your case studies. Thank you for your time and writing. As a PT minded Chiro student, posts like these keep me entertained in some classes that I don’t particularly have vested interest in, like botanical medicine. To each their own.

    The way that this case is screened and treated is textbook mixer chiropractic. All the way from the screening, neuro exam, ROM, MMT, dry needling, mobilizations, strengthening, and manipulation. I appreciate you posting a case like this because I believe that Osteopaths and PT’s or any musculoskeletal expert should use as many tools as possible, albeit with expertise, including dry needling and manipulation. This is one of those cases where a combination, or mixer approach, produced fantastic results.

    Great read. Thanks.

    DJ

  2. Dr. Vaughan,

    Thank you for sharing the case. It was an enjoyable read.

    I am curious. You reported in your objective examination, “Hypomobilility through P/A and lateral glide testing of C0-1 & C1-2 on involved side (negative flexion-rotation test though).”

    Was there suboccipital and/or upper cervical paraspinal hypertonicity causing a false positive on the lateral glide test? More a case of a false negative flexion-rotation test? Or did you have other impressions on the cause of the lateral glide test / flexion-rotation test discrepancy?

    1. Dr. Gaunt,
      Thanks for commenting and good question. The patient had pain at end-range for flexion-rotation test, but did not fall under criteria of 32 degrees. I think the test is a very good one with over 91% specificity and sensitivity, but not 100%. This was one of those misses. Retrospectively, I should have performed more direct testing to determine if most dominant hypomobility was at C0-1 or C2-3, but did not in this case. That could have given me more an answer to your question.

      See ya in a few days,
      H

  3. Nice case study. I couldn’t agree more, the combination of manipulation and dry needling is powerful. I will often release the TrPs in the soft tissue prior to managing via Manipulation as they have less pain guarding and I can be less aggressive with my thrust. Especially true if they have been in pain for multiple weeks as they work there way through the medical system.

    1. Michael,
      Thanks for the comment. I am glad we are on the same page with the power behind these two ‘tools’. Interesting point on soft tissue work prior to manipulation. I do think this is definitely a case by case basis for this decision. Sometimes I’ll rather the region be more “stiff”, but definitely not guarded. This would be a contraindication. Good points.
      H

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