Would vascular testing trump + vertebral artery test in this case?

Screen Shot 2015-12-08 at 8.19.26 AM.pngI read with interest this Johnson et al 2008 Manual Therapy by Dr. Johnson on a patient responding to manual therapy after having a (modified) positive vertebral artery test.  This article is not open access but feel free to contact me if you would like it @ harrisonvaughanpt@gmail.com

The Case

The gist is a 24 year old female patient has a 1 year history of dizziness provoked by left cervical rotation and describes it as feeling of anxiety and difficulty communicating.

The clinician’s decision making prompted him to perform the modified vertebral artery test (VAT)—-which was negative to left—-but positive to right for concordant symptoms of dizziness/slow ability to communicate.

Therefore, he referred out for further investigation via duplex ultrasound—which was negative for any significant stenosis in carotids and vertebral arteries.

Considering the negative radiology report—he then proceeded to examine the cervical spine to identify other possible reasons for the symptomology—in this case, finding several tender points bilaterally in the upper trapezius, SCM, levator scapula and anterior scalene muscles.

Only strain-counterstrain techniques were performed—which resulted in a negative finding of modified VAT immediately, after several weeks and again at one year.

Discussion

Overall, I think this is a great case to add to the literature on the limitations (false-positives) of the VAT and I appreciate the authors for taking the time to write it in a respected manual journal.

My big take home from this is :

  • from knowing the limitations behind the VAT,
  • a one year history of symptomology (it wasn’t stated in article why the patient finally sought care from physio—such as an exacerbation, etc)
  • — I wonder if clinical reasoning to refer out for duplex ultrasound due to positive VAT could be trumped by vascular testing (blood pressure, auscultation).

So my question to you is—

If this patient arrived to your clinic with the above symptomology and vascular examination unremarkable, in other words, blood pressure not elevated, negative bruits—-yes, this is a broad statement—

—-would you make the decision to proceed to a manual examination to confirm or refute your hypothesis that the symptomology is arising from a rotational vertebral artery dizziness condition PRIOR to having duplex ultrasound results?

Looking forward to hearing from you!  We can have more discussion in comment section.

Keep learning—Harrison

 

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Using tuning fork in addition to Ottawa Ankle Rules

I had a female patient come into the office the other day complaining of left ankle pain following tripping on the ice the day before after leaving her home having an inversion ankle injury.  She was currently being treated in our clinic for balance and hip pain, but hasn’t sought care from a medical physician for current complaint.

Upon examination, she was able to walk into the office but marked antalgic gait pattern using a standard cane (which she always uses).  She acknowledged that she was able to walk immediately following the accident and feels symptoms are getting better.  She had apparent swelling in the lateral/inferior aspect of the rearfoot with ecchymosis noted in this region as well (black/blue, not yellow).

Notable objective findings:

Positive Ottawa Ankle Rules with Bone Tenderness at B, but negative for other realms of the guidelines.

courtesy: http://www.bmj.com

She also had negative provocation to moderate depth palpation to the anterior talofibular ligament and posterior calcaneofibular ligament.

Additionally, she had negative pain provocation with 128hz tuning fork at location B and ~4” above this location along fibula shaft.

My course of action was education that I did not think she had a fracture, but I could not rule it out 100%.  She had a positive finding on the Guidelines and it would be best to seek out a plain film radiograph.

Outcome:

She sought care from PCP, had x-rays and they were negative.

Clinical reflection

Therefore, it got me thinking more about how to fine tune the specificity of the Ottawa Ankle Rules, as they only have ~32% specificity, which is very low.  I would suggest the probability of an ankle fracture arriving in a physical therapy office is much lower than at an emergency room (where initial rules arose), therefore, the specificity of this test would be even lower.  So, the average 13% of inversion injuries that are fractures could be more around 5-7%, even lower! Therefore, the rate of false positives would be even higher.  After speaking with her, examining her walking in the clinic (more than 4 steps), the time frame from injury over 24 hours ago and her opinion that it was only a sprain—all gave me a hunch that she did not, but went with the clinical guidelines.  Therefore, I did some research.

I came across this article by Dissman and Han in 2006.  They examined the result of tuning fork test on the tip of the lateral malleolus and distal fibula shaft and compared it to lateral & A/P x-rays following an inversion injury.

Untitled drawing (4)

 

Based on Table 3 above, the sensitivity was still at 100% but specificity increased to 61% to the tip of the lateral malleolus and 95% to the distal fibula shaft, therefore, the specificity increased 3 fold if positive tuning fork test to distal fibula shaft and two-fold to tip of lateral malleolus.

This was only a pilot study and had large confidence levels, so take what you want from it.   I have seen several cases in the past where I did not think there was a fracture, the patient did not think there was a fracture, but the guidelines are unable to rule out.

So, my question to you….do you utilize all 3 aspects of evidence-based practice or rely just on the research guidelines?  I know it is best practice for this case to refer out for imaging, but what about other diagnostics that are less sensitive…such as clinical instability tests and/or vertebrobasilar insufficiency?

 

 

Dissman PD, Han KH. The tuning fork test—a useful tool for improving specificity in “Ottawa positive” patients after ankle inversion injury. Emerg Med J. 2006 Oct; 23(10): 788–790.

doi:  10.1136/emj.2006.035519

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579601/

How would you treat this chronic low back pain case? Follow-up

I wrote a post several weeks ago giving readers history and objective findings of a difficult chronic low back pain case.  Revert back to it before reading on.

Patient was treated in physical therapy for 3 weeks with no expression of improvement per SANE scale, no change per GROC, only short term centralization phenomenon but no carry-over beyond 3 hours, and no changes in pain rating scale (still 6/10 currently, 6/10 at best and 6/10 at worse).  However, Oswestry score did decrease from 56% to 42%, a drop from 28 to 21 points, or 7 point difference.

Therefore, even though high construct of central sensitization, “ramped up CNS”…she was referred out as I wasn’t doing anything for her.

She returned to our office s/p 1 week ESI (epidural steroid injection) for further therapy with following results:

1. Her pain is significantly improved and highest pain has been in a week has been 2/10.

2. No leg symptoms (centralized)

3. Only has taken 1 pain pill in a week (initially took pain pills everyday).

Some insight/questions:

1. She did have a positive crossed SLR on initial evaluation (highly specific for IDH)…maybe she did need ESI based on this finding itself…or as my assumption…she was so ramped up that this gave a false positive finding.

2. Even though functionally improved, patient did not express changes at all with a multi-modal physical therapy treatment so don’t rely on functional scales.

3. It has been only a week s/p ESI, but was this the intervention needed for success?

What are your impressions for referring out for ESI? What signs/symptoms indicate success for this procedure, or is it just failure of PT intervention?

How do I minimize confirmation bias?

“How do I minimize confirmation bias?” was a question directed to me by my current doctoral intern.

The terminology was brought to his attention after I told him that a patient being seen for initial evaluation did not achieve the best treatment due to his preconceived confirmation bias.   What led to this conversation?

-He told me prior to seeing a patient, by just reading medical history report (specifically activities that are deemed difficult to the individual), that considering the individual had difficulty in sustained positions (such as sitting, standing and walking); that the patient would fit the bill for a stabilization program.  He just “knew” this would help her.

– Now, I am all about having an initial hypothesis just from medical history and body diagram, but the subjective history and objective findings should refute or confirm your hypothesis.

– Confirmation bias, even if findings refute your hypothesis, will deter the clinician from applying appropriate interventions based on preconceptions.

– Now granted, he was able to “back it up” per Delitto et al’s Clinical Practice Guidelines for Low Back Pain; but what does latest meta analysis say with strong concluding statement?  Plus, we need to be aware of all 3 pillars of EBP and don’t jump to conclusions too quickly.

In his case, his mind was on a railroad track to just stabilizing the patient without having options.  You know how much I am not on board with this anyway 🙂  Therefore, he did not perform the appropriate history taking and objective findings to refute his findings, just found what he wanted to confirm what he already thought.  Therefore, he fit the bill of a saying, “you will always find what you are looking for”.

So his question to me was, “how do I minimize confirmation bias”

My answers:

1. Firstly, you need to be aware of your confirmation bias.  You can’t change what you are not currently aware of.

2. You can’t avoid it, but you can minimize it.

3. You have to be exposed to multiple intervention disciplines and approaches.   My current intern was preached stabilization in school, past CIs did not teach him anything else but to “use what he knew”, so he is unaware of manipulation, dry needling, and directional preference.

4. Not only being exposed to different paradigms, you need to practice and create patterns within these paradigms.  In theory, this would create more confirmation biases, but then again, it will allow you build a strong foundation that holds up the 3 pillars of EBP.

This is a start.  What are your thoughts?  How do you minimize confirmation bias?

 

 

What is the tissue source in low back pain?

As I speak with more clinicians, I get wider and wider views of what the tissue (soft tissue or inert) source in low back pain.  For sake of this post, let’s say chronic low back pain…dubbed non-specific low back pain. The most common answers are the:

1. Intervertebral disc

2. Facet joints

3. Myofascial

4. Sacroiliac joint

5. None (unless symptoms are acute, pain does not equal tissue damage)

Training, type of patients, treatment approaches, research, media, and beliefs all play a combined role in creating a bias.  Two of my mentors are on exact opposite ends of the spectrum.

For instance, here is an example of the diversity in ratio:

Clinician 1: Sacroiliac Joint (80%), Facet Joint (10%), Myofascial (10%)

Clinician 2: Intervertebral Disc (30%), Facet Joint (60%), Sacroiliac Joint (10%)

DePalma et al in 2011 estimated the prevalence rates of discogenic, facet and sacroiliac joint in chronic low back pain patients whom have been in motor vehicle accidents.  After having diagnostic procedures that are “criterion standard” for diagnosing either of the 3 conditions above, here are the results:

Of the 27 patients, 15/27 (56%) were diagnosed with discogenic pain, 7/27 (26%) with sacroiliac joint pain, and 5/27 (19%) with facet joint pain.

The author’s conclusions:

Our study is the first to demonstrate that diagnostic spinal injections can identify particular spinal structures, namely the intervertebral disc, facet joint, and sacroiliac joint, as the specific source of chronic low back pain due to inciting motor vehicle collisions. The most common source of motor vehicle collision-induced chronic low back pain appears to be the disc followed by the sacroiliac and facet joints.

Granted this is a subgroup of chronic low back pain patients (small n too), but based on this data…

Clinician 3: Intervertebral Disc (55%), Sacroiliac Joint (25%), Facet Joint (20%)

Quite the variability right?

I want to know what YOU think.

I have had success in the past with polls (EBPpre-manipulation hold, and osteopractor word of the year), so I hope to get lots of engagement!

You know you see low back pain.

You know you have an opinion.

So let’s ALL engage to get a true sense of what clinicians think ALL over the world.

To participate, choose your TOP tissue choice of low back pain.  Then in comments, provide a ratio as I did above, your profession and explanation behind your rationale.

Differential Diagnosis – Low Back and Leg Extremity Case: Part 3

I recommend reading part 1 here and part 2 here prior to reading further on a challenging differential diagnosis case.

Below is a copy of this patient’s lumbar spine MRI.

Differential Diagnosis Low Back and Leg Case
Differential Diagnosis Low Back and Leg Case

Based on subjective and objective findings from part 1 and part 2, as well as a Normal MRI of lumbar spine as noted above, what is your impression of this patient?

How would you treat this chronic low back pain case?

Subjective History: 35 y/o female presents with hip and back pain.  She had no injury or accident but has been dealing with back pain for 5-6 years.  She sought care from surgeon who ordered MRI (5-6 yrs ago) that showed DDD but that she was too young for surgery and has to deal with the pain.  In Feb 2014, her right hip “gave out” on you on her way to work one morning.  The sensation was a pinching in the groin that hurt on every step.  It hurt so bad that she went to ER who then referred her to Dr. *&$^(.  She has had multiple x-rays, bone scan and then MRI of hip showing a torn labrum in April 2014.  She wound up losing her job after 14 yrs due to not being released to go to work.  She had another consult in Sept 2014 with a surgeon for hip, but was told to lose weight and she was not a candidate for surgery.  She started another job (that involved 8 hrs of standing) shortly thereafter but after one week, she could hardly stand due to right hip pain arising again and numbness in right leg.  She then sought care from her PCP, Dr. *^%*, who referred her for CT scan (for back) and then to Dr. *$&^.  She had a consultation and then referred to PT.  She was told she would have injections.

Onset

Date of Onset: Back pain and numbness in right leg for past 5-6 years. Right hip pain started Feb 2014. In 2010, she had to have ambulance get her from her house due to her back giving out and right leg “stuck” resulting in her having to be put asleep to get the right leg extended again. Onset Due To: Unknown. Recent Symptom Trend: Condition worsening.
Symptoms
Primary Symptoms: She c/o numbness down right leg from hip posteriorly to 5th digit. Provokes symptoms: Any movements. Hurts with standing/walking/sitting and doesn’t matter what type of chair. Relieves symptoms: trying to stretch (nothing specifically) and sometimes medication.

Pain Rating:

Currently: 6.5/10, Best: 3.5/10 (between stretching and medication), Worse: 10/10 (see above but also occurs weekly).

Sleep Disturbance: She barely sleeps. She tosses and turns all night only getting 4-5 hours. This has been going on for years.

Vocational
Current Status: Not working. Has lost 2 jobs in last few years due to functional limitations.

Objective
FABQ (work): 19, FABQ (physical activity): 22.

Oswestry: 56%

Observation: Unable to stand without dysfunctional pattern and using B UE for support.

Observation: Single leg stance 5″ on left limb, 1″ on right limb.

Palpation

Hypersensitivity along entire lumbar spine from L1-S4 mostly centrally > laterally ~3 fingerbreadths from SP

Lumbar Spine Flexion: 
Very restricted to patella bil and pain low back (all AROM equally painful in same location in LB)
Lumbar Extension:
Very restricted
Only ~5 degrees. (all AROM equally painful in same location in LB)
Lumbar L Side Bending: 
Very restricted
Only ~10 degrees. (all AROM equally painful in same location in LB)
Lumbar R Side Bending:
Very restricted
Only ~10 degrees ((all AROM equally painful in same location in LB))

Reflex Tests
Achilles Tendon Reflex (S1)
Absent (0) on right, 1+ on Left
Patellar Tendon Reflex (L4)
Diminished (1+) bilaterally

Neurodynamic Tests
SLR
Positive
~40 deg SLR for LB but not leg symptoms on LEFT, and ~20 deg SLR for LB but not leg symptoms on RIGHT (+ crossover)

Lower Extremity Dermatomes (to sharp prick):
L1: Inguinal Region: Intact

L2: Upper Thigh: Intact

L3: Mid Thigh: Intact

L4: Patella, medial leg, medial malleolus: Intact

L5: Dorsum of foot, 3rd metatarsophalangeal joint: Intact

S1: Lateral aspect of calcaneus, lateral aspect of posterior leg: Diminished
Absent to lateral aspect of foot from calcaneus to MCP of 5th digit.

S2:Medial aspect of posterior leg: Intact

Lower Extremity Myotome Strength

L2: hip flexion: 4/5
Generally weaker on right side
L3:Knee extension: 4/5
Generally weaker on right side
L4: Ankle Dorsiflexion: 4/5
Generally weaker on right side
L5: Great Toe Extension: 4/5
Generally weaker on right side
S1: Ankle Plantarflexion: 3-/5
Unable to perform single calf raise on RIGHT, 18 reps on LEFT
S2: Knee Flexion: 4/5
Generally weaker on right side

With the information provided, how would you proceed? What other objective/subjective information do you need?  Is this individual appropriate for PT services?

Medical Screening Course – MedBridge

I recently took Dr. Michael Fink’s course on MedBridge, Medical Screening and Differential Diagnosis – Systems Based Approach. This provided me 6 contact hours of medical screening and review of specific systems, which goes beyond the minimal necessary to fulfill my continuing education needs. I embrace my role as a Direct Access practitioner. Not only did I decide to take this course as a requirement, but also as a service to my patients as I’m trained in differentiating between systemic and musculoskeletal conditions.

Access the full article here.

If you are looking for a last minute Holiday gift to give out to someone this season—who may possibly be a PT, who may possibly love to learn all the time, and a gift that just keeps on giving…then check out MedBridge Education.  If you enjoyed the article and want to seek out more learning opportunities, try them out for a year.  Be sure to use my promo code for a special price that can’t be beat.  Be sure to type in inTOUCH before you check out (in is lowercase while TOUCH is capitalized). 

Thanks for reading!

DIFFERENTIAL DIAGNOSIS — LOW BACK & LOWER EXTREMITY CASE: PART 2

Before reading the objective findings below, make sure you read the subjective history taking in Part 1 here of this differential diagnosis case.

Observation: Slouched posture. Decreased lumbar lordosis.

Gait: Stiff leg, wide-based gait pattern with very little knee flexion and hip extension.

Tenderness: Generalized tenderness in lower lumbar spine and SIJ with no particular one location.  This is the same in weight-bearing (standing/sitting) and non weight-bearing (prone).

Palpation: No warmth to and around the lumbar spine and pelvis.

Lumbar ROM: Painful in all directions but only limited by 25%. No particular DP. Symptoms are generalized in lumbar spine.  No peripherlization or centralization of symptoms with repeated movement exam in standing or prone.

Hip and knee ROM: Normal and unremarkable in all planes.

MMT: 4/5 hip flexion that causes low back pain.  Both knee flexion and knee extension is 4+/5 that also causes low back pain.  No myotomal weakness or remarkable findings distally.

Neurological: 

– Negative SLR and prone femoral neural tensioning test.

3+ B L4, 3+ B S1.

+ Babinski

– Hoffman sign

– Supinator sign

– 2+ B C5-C7

Based on the above information,

What are your top 3 differential diagnoses?

What type of information did you gain from the video above?

What other objective findings would you look for / test?

Would you treat, refer or treat and refer; and why?

Differential Diagnosis — Low back & lower extremity case: Part 1

Looking for feedback on this case.  Questions will be provided at end of blog post below case.

Script: Lumbar Disc Herniation.

Medical History: (I am listing the “Yes” remarks from intake form):

-Positive for arthritis

-Positive for sleeping difficulties

– She smokes 1/2 pack a day and 4 packs a week

– She doesn’t work out but does enjoy walking sometimes

Subjective History: 32 yo female presents with main complaint of back pain and BIL LE. It all started with Bil LE pain but she has had a history of low back pain which was just uncomfortable, but now it is unbearable.  This arose during the month of August following a surgical procedure following a miscarriage (patient was unsure of procedure but I am assuming D&C).  She consulted with her surgeon but he is unsure why she is having symptoms following this procedure.  She was then referred to a spine surgeon who referred to PT for 4 visits until he can order an MRI.

Prior history: She has had one other miscarriage in the past.  She says she is not sure why she miscarriaged then and even now.  Her MD doesn’t know either.  She is not sure if her mother had miscarriages either.  She has one son who is 6 years old.

Date of Onset: Mid-August 2014 (4 months ago). Onset Due To: Arose after D&C.

Recent symptom trend: Since August, the pain has spread from the thighs to the low back. Pain is mostly in the thighs, but will work to the calves at times, but cannot provide any further information of why.

Pain Rating
Verbal Pain Rating at Present: 8 /10
Verbal Pain Rating at Best: 6/10 (Over the past week)
Verbal Pain Rating at Worst: 10 /10 (Over the past week)

Quality of symptoms:  She describes the back pain as unbearable at times.  But for the most part, everything is just “sore”.  She has trouble moving around.  She feels like everything needs to pop. Her symptoms are mostly in the thighs, equally bilaterally, and circumferentially.  She says this is numbness/tingling and burning.  She also describes muscle spasms in the same location that is painful.

Provokes symptoms: Any movements could do it, but also she can have muscle spasms that arise just sitting.  She denies any postures, movements or positions that make symptoms better or worse.   Relieves symptoms: Lying down with heating pad (legs elevated).  Medication as prescribed.

Medication: Prescribed muscle relaxer (Skelaxin) that she takes 1-2x/day as needed.  Was prescribed a 10 day prednisone series

Sleep: She only gets half the amount of sleep than she did prior to procedure.  She says she wakes up several times a night and it can keep her awake for several hours at at time.  She just lies there and watches TV.

Further questioning:  PT in italics, patient in normal font.

Are you having any changes in your bowel or bladder? No.

Are you having any painful urination or bowel movements? No.

Are you having any pain with intercourse? No.

Any discoloration in your urine or bowels? No.

Are you having any abdominal pain? Yes but only came on after taking Diclofenac as prescribed by MD.  However, I am not taking this medication anymore due to the effects.

Where was it hurting in your abdomen? Generally in lower abdomen pointing diffusely in this region.

Do you notice the lower limb symptoms at different times of the day? Yes, it gets worse as day progresses but blames it on just being active to do daily tasks.

 

What are your top 3 diagnoses so far?

What other questions would you ask prior to proceeding to objective exam?