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Runner with hip pain: progress & reassessment

By guest blogger, Susan Bamberger

The patient is better, but symptoms are not fully resolved. In determining the next step, considerations include the following:

  1. Analysis of the exercise:
    • Is he performing the exercises as prescribed?
    • Is he reaching end range?
    • Is the exercise correct?
  • He is performing the exercise correctly, and he is reaching end range. It is too premature to abandon the exercise. In one visit, he is demonstrating improvement, as he can run longer and with less pain.

2) Is he doing anything between the exercises that may aggravate his symptoms?

  • In his detailed journal, he had stopped all the other stretches as requested, and had not really changed his regular routine. He was not doing anything in his life that might aggravate the hip.

3) Was there anything about the posture of running that might aggravate his symptoms?

  • In this case it made sense to assess his running posture. This was not a running gait analysis, but rather an evaluation of the hip posture in relation to the understanding that his range of motion decreases and pain is produced when running. A derangement causes a mechanical obstruction, and therefore I wanted to see what it was about his running that was causing the mechanical obstruction.
    Example of the running posture he was assuming:

McKenzie runner b

With the forward flexed posture, it was reasonable to conclude this may contribute to his pain presentation. He was experiencing 2/10 pain when running during this demonstration, as he had just run over for the visit. So, I asked him to stand more upright by engaging his hip extensors. With this positional modification, his pain went away.

Visit three

Two days later, the patient returned, reporting he could run longer- 15 minutes, vs 10 minutes before, He reported he was learning to run upright, but was not able to maintain his upright posture, When he experienced pain, if he corrected his posture, the pain went away immediately.

Correcting posture with activities can be a process that takes a long time to correct. It is best to correct the pain before the pain comes on, but at first this may be challenging. With diligence, he should be able to permanently fix his running posture and avoid aggravation of his symptoms.

Since we were on visit three and he still could only run 15 minutes, it made sense to reassess the effects of the exercise. It was not completely clear that the stretch prescribed was enough to fully reduce his symptoms. At this point, it made sense to intentionally aggravate the symptoms through progressive mechanical loading to determine what it takes to fully reduce the symptoms.

Pt had 0/10 pain prior to the start of the start of this test. The patient performed unloaded hip flexion, or walking marches: there was no effect. I then had him perform walking marches into a full lunge, which reproduced his symptoms to a 3/10 and reduced his range of motion .I then had his perform his prescribed exercise, which reduced his pain to 2/10, but did not abolish it. I then encouraged him to hold his stretch 5-7 seconds longer, which abolished his symptoms altogether.

His instructions were to hold his stretch a little longer, and to gradually increase his running, integrating the prescribed exercise into his running, Some minor adjustments of the exercises gave him the results he wanted- a full resolution of symptoms.

He was given guidelines for getting back to running up to 30 minutes at a time. He was given the guidelines for pain production. He was instructed not to be afraid of the pain, but to respect it and be sure to move it when he feels it, so as to not aggravate it as he had during the marathon. He was instructed on what to do if his hip does truly worsen to the point that it causes constant pain; to perform the stretch regularly and take a few days off from running.

Visit 4: 2.5 weeks later

The patient was pleased that he was able to run up to 30 minutes without exacerbation of symptoms. He was so pleased with this progress that one day he tried running faster with some of his running buddies, which pushed his hip harder and further than he had been. During that run, he got the same 5/10 pain he had at the marathon. After the run, he immediately went back to the hip extension exercise. While they helped, they did not immediately abolish his pain as they had before.

An exacerbation of symptoms can be used as a learning tool for the patient; to see if they understand the principles of self management. McKenzie and May state in The Lumbar Spine: Mechanical Diagnosis and Therapy (2004) “At the first sign of recurrence, the patient should immediately commence the procedures that led to recovery”. Learning how to manage symptoms when they recur is a key to long term recovery and prevention of disability.

To determine if he understood these principles, I asked him what he did. He understood that he had run too fast and too far, and was not ready for it yet. He immediately went back to an increased frequency of hip extension in half kneeling, and stuck with them regularly for 2 days. He also stopped running altogether for a few days. Within a few days he felt much better, and was ready to start running again.

Using the last visit as a baseline, we tested the irritability of his symptoms through progressive mechanical loading. I ran him through the same litany of tests as before. Standing hip flexion had no effect. Walking marches into a full lunges had no effect. He then performed many squats, lunges, lunges with torso twists, and side lunges over the course of 25 minutes. None of these symptoms reproduced his symptoms or created any mechanical change, indicating a vast improvement from the testing we had performed during the last visit. My instructions were to continue with self treatment and gradually increase his running program.

The patient came in three more times over the course of four weeks. During these visits, we would mechanically test the hip as we had previously done. His hip remained stable, as there were no mechanical symptomatic changes with progressive loading. At this point in the program we started to work on hip strengthening exercises. He wanted to return to the exercises he was doing before, so we reviewed what he was doing and discussed how he could integrate the hip extension exercise into his exercises: If he overdid the strengthening and his left hip pain resumed, he could utilize the hip extension exercise to self manage his symptoms.

By the time he was discharged, he was running pain free up to 10 miles at a time, at his desired pace. He was contacted a few months later for permission to publish this case study He reported he was gradually increasing his running, was still painfree, and was on track for his next marathon..

In 8 visits over 6 weeks, this runner progressed from not running at all to training for a marathon again without pain. As health care changes, we have to be poised to prove our value in providing cost effective care. Ask yourself:

  1. How can we set ourselves apart as leaders in health care? What services can we provide that patients find valuable in this information age?
  2. How can we maximize health care dollars and prove to our payers that physical therapy is a valuable tool?
  3. What tools are you going to use to prove you are effective and necessary?

Thank you for your attention to this case study. I have enjoyed hearing from so many of you and hope you have received value through this exchange. Feel free to leave any parting comments below. Warmly, Susan.

 

A FINAL NOTE FROM EDUCATA:

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ASSESSMENT: zeroing in on the problem with our runner

 By guest blogger Susan Bamberger

Thank you all for your detailed and well thought comments on the first installment of this case study! At the end of the history, we should have some idea of what might be going on. Performing a detailed interview will help to create hypotheses that we can test in the physical examination.

Giving some thought to pathoanatomical causes, it is possible the he may have a tendonosis of the psoas. It is also possible that he has a mechanical impingement of the hip joint. He may also have a structural defect such as a labral tear. The symptoms could be coming from the lumbar spine or the hip, SIJ, knee or foot. It is also possible that he has a stress fracture. Each of these pathoanatomical possibilities are managed in different ways. How do you discern which to treat?

While the pathoanatomical possibilities are there, we do not have the ability to look inside and determine the exact cause. The most accurate information we have in front of us in this visit is the patient’s pain presentation and its behavior of symptoms. We can look at the behavior of symptoms and assess for change in these symptoms through the course of testing. This will become the most effective guide in developing a plan of care.

My assessment utilizes Mechanical Diagnosis and Therapy (MDT) which is used to target the problem based on symptom presentation and behavior. More common in the spine, MDT has proven to be reliable, valid and prognostic in multiple studies conducted over the last 40 years. However, the principles of assessment can easily be utilized in any joint of the body, including the hip.

As I begin to plan the physical exam I must consider all of the factors contributing to his recovery:

  • The pain is a 5/10 on a 0-10 scale, 0 being no pain and 10 being the worst pain ever imagined.
  • It comes on as soon as he begins running and it ramps up immediately. However, it goes away within a few minutes after stopping his run.
  • He does not notice the pain otherwise- he sleeps well, and does not feel the pain when going up and down stairs.

He has been trying to run every few days, without any noticeable change. Any objective baselines I find must be related to the exact pain he experiences when running. However, he was not prepared to run on this visit, so another baseline will need to be used.

To get a solid baseline, I may need to be pretty aggressive in my examination on day one. However, in order for trust to be established, I decided not to try and provoke his symptoms, but rather to educate him in the assessment process and the need for him to participate in the analysis.

The location of symptoms indicates the pain could be coming from the hip or the lumbar spine. The behavior of symptoms does not exclude the hip or lumbar spine. So a screen of the lumbar spine was necessary before exploring the hip in detail.

The physical exam reveals an athletic man in no apparent distress. Left hip passive range of motion into flexion, abduction internal and extension rotation were tested in supine. IR and ER were tested supine in 90 degrees flexion. Extension was tested in side lying. Flexion ROM is approx 100 degrees and painful. Abduction is approx 25 degrees and painful. There is a minimal loss of internal and external rotation, with pain greater into external than internal rotation. Extension lacks approximately 5 degrees to end range.

Resisted motions are strong and painless in all directions except flexion and adduction, which are weak and painful. These tests were performed in supine. Resisted flexion in supine, in particular, produced his primary pain. This was the baseline to refer back to when I perform my mechanical testing later.

While special tests ( Hip scour, compression) could be performed, none were performed on visit one. The patient had been referred from his orthopedist, who was confident there was not an operable structural issue, and there was nothing yet in the history that indicated surgical referral. At this time, special tests did not have a practical use. If there was not a consistent response to the repeated motions, at that time special tests may be indicated for further clarification.

Screening for the lumbar spine did not reveal any significant lumbar component. This was done by first checking for lumbar range of motion in standing, flexion, extension and side gliding were  within normal limits. To determine if the lumbar spine was involved, 15 progressively loaded lumbar extension mobilizations were performed in prone, and then his primary baseline ( resisted hip flexion in supine) was retested for change. There was no change, indicating it was necessary to move to the hip for further testing.

The next step is the repeated movement examination, a key component of the MDT assessment process. Responses to symptomatic, mechanical and functional baselines give us the information needed to classify his condition and devise a directed and effective treatment plan. Repeated movements can be performed dynamically, with sustained positions or with resistance. If the baselines demonstrate an immediate and lasting change, the classification is derangement and the prognosis is excellent.

Repeated hip extension in half kneeling was the first movement chosen. Given the irritability of the symptoms, half kneeling would provide a great deal of force, and is a good start to providing movement that will provide immediate and lasting results. The direction of extension was chosen as this is often the direction most frequently seen for patients with hip derangements. The position of half kneeling was chosen as a relatively aggressive position, knowing that since an aggressive force was needed to produce the symptoms, that an aggressive force would be needed to reduce the symptoms.

The patient had 0/10 pain at the start of the repeated motions exam. There was some pain at the end of the range of the first repetition, in the same location as his primary pain. This pain progressively improved with subsequent movement, as did his ability to move further.

In retesting his primary baseline (5/10 pain with resisted hip flexion in supine), 10 repetitions of dynamic hip extension in half kneeling reduced his pain to 4/10, and 10 more reduced it further to a 2/10. His ROM in all planes were restored to symmetrical and within functional limits.

runner flexing

With an immediate and lasting change in range of motion and pain, the repeated motions exam confirmed a classification of derangement, indicating an excellent prognosis. As his pain decreased, his strength also improved, indicating the weakness with resisted hip flexion was more likely related to pain inhibition than true strength loss.

Since we have not actually tested running, we cannot conclude that this movement alone will resolve his primary pain. However, since we were able to find a baseline that reproduced his primary pain, and it changed with the repeated motions exam we have something to start his treatment plan.

The patient was sent home with instructions to assess the effects of this test over the next few days. He was instructed to discontinue any other stretches he was performing, and to perform just this one exercise until he came into the clinic again. This would help to determine the effect of this one stretch alone. Specifically, he was instructed to do hip extension in half kneeling, 10-15 times, 4-5 times throughout the day. In a few days, he was instructed to test running, to see if a few days of the repeated hip extension in half kneeling produced any positive results for running. Pt understood the mechanical issue, and experienced the immediate results during our assessment. He was eager to take a role in the analysis of his symptoms.

Visit two

Four days later, the patient presented to the clinic with a journal describing his pain behavior and exercises. There was a consistent effect with the exercise: immediate discomfort, then a loosening of the range of motion and a lessening of pain with each subsequent repetition.

He had tried running two days, and was encouraged as he could now run 10 minutes before experiencing pain. In addition, the pain was not as intense- it was a 2/10 instead of a 5/10 as before. He ran to the clinic for this visit, and was experiencing a 2/10 pain towards the end of his run to the clinic. He demonstrated the exercises, and was performing them correctly.

The patient is better, but is it enough to continue with the current plan of care?

What would you like to add to his home program at this time?

What would you do on this visit?

What other treatments would you want to apply, and why?

How would you help this runner?

Introduction by Marilyn Pink: from time to time EDUCATA has the privilege of hosting guest bloggers on this platform. This series is written and moderated by Susan Banberger, a PT since 1999. Susan is a Diplomate in Mechanical Diagnosis and Therapy and works at Advance Sports and Spine Therapy in Wilsonville, OR. She has contributed to several publications, including the International Journal for Mechanical Diagnosis and Therapy. 

The case study examines the experience of a runner who has recently dared long distances and comes to the PT with severe hip pain.Please feel free to participate and comment at the end of the article, as much is learned by all in the process of exchanging ideas.

A runner with hip pain – getting him back in the race

By guest blogger Susan Bamberger

When a runner comes to physical therapy with debilitating hip pain, there are a multitude of treatment options. The accessibility of information from the internet leaves patients confused as to which shoes they should wear, if they should wear shoes at all, if they should stretch, and if so, should they stretch before or after their run, or both? They come to us to help sort out this information and to determine what is best suited for them.

Physical Therapists have the responsibility to create an effective plan for each patient in a reasonable amount of time. Not every treatment works for every patient. Anyone can research stretches, strengthening and shoes on the internet. Our challenge is in proving that we hold unique knowledge and skills to deal with individual problems in this information age. This case study is an example of how skilled physical therapy provided excellent results and gave this runner the knowledge and treatment he needed to return to running, pain free.

physical therapy runner with hip pain

The patient is a 38 year old male plant manager and new long distance runner presenting with complaints of left anterolateral hip and thigh pain. He was referred to physical therapy from his orthopedist, who diagnosed him with greater trochanteric bursitis.

His onset of symptoms was 6 weeks prior to the initial evaluation, after running a marathon (26.2 miles). By the end of the race, he was in intense, constant pain, rated at a 5/10 that remained constant for 3 days after. His symptoms became intermittent, and have not changed much since that time. His plan was to run 4 marathons in the next year, but he has stopped running completely, as every time he runs the pain comes back to the same intensity it was immediately after the race.

Since becoming symptomatic he has tried many stretches and strengthening exercises he researched on the internet. He has also received advice from his massage therapist. However, the same pain comes back when he runs. He has good shoes, and changes them every 250-300 miles, per industry recommendations. Because of all of his research, he is concerned that this is an issue that is going to keep him from running altogether.

When asked if the patient had any imaging, he replied “only an xray”. Then he said, “Why, do you think I need an MRI?” Sensing fear of life-altering structural damage, the patient was assured that one of the goals of physical therapy is to determine the right place for them. With a careful assessment over 2-3 visits, we should know if further testing is necessary.

Given the history, which structures are you going to examine?

How can we establish functional baselines and how vigorous can we be in our examination?

What examination tests would you use, and why would you use them?

We look forward to your comments!

My Own Approach To This Case

INTRODUCTION, by Marilyn Pink, PT, Ph.D. — And so, we arrive at the 4th and final post in this case study by Dr. Landel. We hope that you’ve acquired new insights, and we very much appreciate your comments. They provide additional dimensions to a discussion that is, by all measures, very rich. So, don’t be shy and participate once more, as Rob closes out with icing on the cake!

Rob Landel

Guest blogger Rob Landel, PT, DPT, OCS, CSCS, FAPTA

What would be your initial treatment intervention?

By guest blogger, Dr. Robert Landel

  • The cervical spine has some significant impairments, understandable given her recent MVA and complaints of neck pain.
  • All PE findings suggest a normal central nervous system.
  • Oculomotor exam suggests no central vestibular pathology.
  • Head thrust suggests no peripheral vestibular hypofunction.
  • Report of instability (without falls) suggests a balance issue. Balance testing reveals a normal Rhomberg, but this is not a sensitive test. Sharpened Rhomberg, mCTSIB and SLS testing suggest further that there are balance issues. Of interest is the difficulty with SLS while the head is rotated right.
  • Flexibility tests are non-contributory but you might consider addressing these.
  • Positional testing is positive and suggests a right posterior canal canalithiasis BPPV. Horizontal canals appear normal

Thus, my approach would be to address the BPPV first using a canalith repositioning maneuver, or CRM. This is highly likely to resolve the BPPV within one treatment. My preference is to do one CRM, and send the patient home without doing other treatments, with a return visit in a week or sooner. I do not give post-CRM precautions.

As to prognosis…

As I noted above, very good for the BPPV. (Helminski et al., 2010) However, patients can have continued complaints of dizziness despite resolution of their BPPV (as defined by no nystagmus or vertigo during the Dix-Hallpike maneuver). (Seok et al., 2008)

In this patient’s case she complained of continuing dizziness despite a successful CRM. Since there were no central vestibular signs, and once the BPPV was cleared there were no clinical signs of peripheral vestibular pathologies, the possibility of cervicogenic dizziness comes to the forefront. This is particularly true when the dizziness is accompanied by neck pain. (Wrisley et al., 2000). As noted above, the difficulty with SLS while the head is rotated right is significant; this suggests that the cervical spine is playing a role in her postural instability. Further testing is warranted at this point, and in particular, testing for cervical sensorimotor impairments. An excellent article to review this is by Kristjansson and Treleaven (Kristjansson & Treleaven, 2009) and I highly recommend you read it if you treat patients with neck pain. To summarize, sensorimotor impairments can cause a variety of symptoms, and clinical tests are available to help determine the problem and potential solutions. The table below is a summary:

Each component needs to be assessed and treated. Here are some suggestions:

JPE:

  • Use a laser on the head to provide feedback while the patient practices returning the head to a starting position, eyes open (knowledge of performance) and eyes closed (knowledge of results).
  • neck flexor strengthening improves head JPE. (Jull et al., 2007)

Neck Movement Control:

  • Practice tracing patterns using the laser on the head.
  • Strengthen the deep neck flexors and the cervical and capital extensors.

Postural stability:

  • Neck extensor endurance is also very important for postural control; subjects whose neck extensor muscles fatigue have been shown to have increased postural sway. Just as importantly, the authors were able to improve postural sway by training the neck extensors. (Stapley et al., 2006)
  • This patient exhibits some LE impairments that will adversely affect balance, namely LE weakness, and these will need to be addressed.

Oculomotor control: practice smooth pursuit with the head in neutral and with the body turned underneath a stable head. Do the same with saccades.

Let’s not forget the other cervical spine impairments we found earlier, mainly, reduced ROM. For this, use your joint and soft tissue mobilization, whichever particular flavor works well for you, and follow your manual therapy with appropriate exercises.

I hope you found this patient case interesting, and I welcome comments and suggestions. Perhaps I’ll see you at a future course or conference!

Best regards,

Rob

References

Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: A systematic review. Phys Ther 2010: 90(5): 663-678.
Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: The effect of two exercise regimes. J Orthop Res 2007: 25(3): 404-412.
Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: Implications for assessment and management. J Orthop Sports Phys Ther 2009: 39(5): 364-377.
Seok JI, Lee HM, Yoo JH, Lee DK. Residual dizziness after successful repositioning treatment in patients with benign paroxysmal positional vertigo. J Clin Neurol 2008: 4(3): 107-110.
Stapley PJ, Beretta MV, Dalla Toffola E, Schieppati M. Neck muscle fatigue and postural control in patients with whiplash injury. Clinical Neurophysiology 2006: 117(3): 610-622.
Wrisley DM, Sparto PJ, Whitney SL, Furman JM. Cervicogenic dizziness: A review of diagnosis and treatment. J Orthop Sports Phys Ther 2000: 30(12): 755-766.

What Is This Patient’s Prognosis?

INTRODUCTION, by Marilyn Pink, PT, Ph.D.: Dr. Landel ended  last week’s post with some thought-provoking questions. Here he provides instructive answers — in many cases matching some of the comments left by you. As we learn more, more is revealed. In this next post, Dr. Landel tells us what he found on his physical exam of our patient, and leaves us with new questions, including the one about her prognosis. Take a look and let us know what YOU think, and why!  Best,

Marilyn

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Rob Landel

Guest blogger Rob Landel, PT, DPT, OCS, CSCS, FAPTA

Physical Exam Findings

But first, a recap of the questions posed at the end of last week’s article, with my stab at the answers:

1)     What are the most likely causes of the patient’s dizziness?  Support your choices with the known facts.

Given the paucity of information to rule many diagnoses out, I would argue that the list of possible diagnoses should be long. In addition they should cover many different systems (e.g. neurologic, vascular, vestibular) and processes (inflammation, infection, trauma, degeneration). Thus, we could consider:

  • traumatic causes, such as fractures of the spine or head, torn ligaments (e.g. alar, transverse), BPPV (since ~50% of reported cases have a history of trauma associated with onset), or cervical spine injury
  • inflammatory processes such as seen in RA or even OA of the spine
  • infectious causes (e.g. sinusitis, acoustic neuronitis, labyrynthitis, some type of brain infection)
  • metabolic issues (related to medications for example)
  • vascular pathologies (e.g. VBI, orthostatic hypotension)
  • degenerative, such as TMJD, BPPV (since the other ~50% of cases don’t have a history of traumatic onset, and it occurs frequently in the elderly, could we consider it a degenerative process?), OA of the C-spine
  • tumors, such as acoustic neuroma
  • neurogenic causes, such as MS or TIA’s
  • psychogenic issues such as anxiety

Just a brief list, of course there are others. Did I miss any that you thought of?

2)     Are there any pathologies that may be causing her symptoms that are concerning to you (even if they aren’t likely causes)? If so what are they, and how would they present?

We got a lot of great suggestions in the comments to the last post, including checking for VBI, upper cervical ligamentous stability (alar ligament and transverse ligament were mentioned, we could have added tectoral membrane), looking for central neurologic signs and in particular looking for evidence that the patient’s neurologic condition was changing unexpectedly. The presence of any of these conditions should be concerning, could cause the patient’s complaints, and would require referral for further workup before commencing any therapy that would involve head or neck movements. One might also consider a cranial bleed, but given the time since the MVA, the short duration and episodic nature of her symptoms this is less likely. We could and should consider systemic disorders, such as RA or infection, and of course the presence of tumors. Since she has a history of trauma, we should consider fractures, however unlikely (as suggested by the Canadian C-spine Rules (Stiell et al. 2001 JAMA). Finally, other cardiovascular pathologies besides VBI should be considered, particularly if the patient describes her dizziness has been similar to the pre-syncope symptoms one gets with orthostatic hypotension and arising from a supine or sitting position too quickly.

3)     What questions would you ask of your patient, and why?

There are a multitude of questions that could help clarify her condition, and that will a) help determine if this condition is benign or serious, and b) will not delay further treatment or provoke further complications. I think Jennifer’s comment to the last blog post was excellent, and is worth reading because it contains the answer to this question as well as the others. Rather than repeat her response here, I’ll direct you to it.

4)     What physical examination would you perform at the initial evaluation?  Prioritize your tests and measures, and justify your answers?

There are a many tests that can be performed that will a) help determine if this condition is benign or serious, and b) will not delay further treatment or provoke further complications (Froehling et al., 1994). Specifically, Froehling et al. suggest that if the patient is over 69 years of age and has a positive neurologic exam that there is a 40% chance that their vertigo is serious in nature, serious being defined as “due to conditions associated with increased mortality or long-term disability. Vertigo severe enough to impair daily functioning and lasting for more than a month would be included as a serious form of vertigo.” (Froehling et al., 1994)

One of the key points of this studywas that positive neurologic findings  were a key to determining if the cause was serious; therefore there is good evidence for doing a thorough neurologic examination that would include sensation, motor function, reflexes, cranial nerve exam, coordination, cerebellar tests, and abnormal reflexes. In considering the concern over the presence of VBI or upper cervical instability, it is clear that most of the neurologic examination can be performed without adversely affecting the vertebral arteries or the upper cervical ligaments.

Again, I would refer the reader to Jennifer’s comment, which is quite thorough. Once you’ve gone through that, read on for the physical examination findings.

PHYSICAL EXAM FINDINGS:

Self-reported Outcome measures: DHI 45/100, NDI 30/100

Special Tests:

Upper cervical ligament and membrane stress tests are normal.

Sustained positioning of the head in her available range of motion while in sitting does not increase her dizziness.

 Cervical Active Range of Motion:

Flexion:                0°-50°

Extension:           0°-35°, complaints of pain

Right rotation:     0°- 55°, complaints of discomfort

Left rotation:        0°-70°

Neurologic exam

Reflexes: 2+ upper and lower extremities.

Sensation: Intact to vibration in upper and lower extremities.

Motor:

Manual Muscle Tests:              Left                             Right

Hip flexors                                      4/5                               4/5

Quadriceps                                     5/5                               5/5

Anterior tibialis                               4/5                               4/5

Plantarflexors                                12 heel raises          15 heel raises

Gluteus medius                              3+/5                           3+/5

Neck flexion                   3/5, endurance <5 second hold

Neck extension             3+/5, endurance 30 second hold

Upper Extremity:          4+/5 throughout, bilaterally

Pathologic reflexes:    Babinski (-), Hoffman’s (-)

Cerebellar tests:          Intact finger to nose, heel-shin tap, rapid alternating movements.

No hypertonicity is noted with fast passive movement of the extremities.

Oculomotor Exam:

Ocular alignment and motility normal.

Absent spontaneous or gaze-evoked nystagmus in room light.

Saccade testing normal.

Smooth pursuit normal.

VOR cancellation normal.

VOR to slow and rapid head movement (head thrust, in pain-free ROM) normal.

Gait:

She is able to walk without assistance but demonstrates decreased step length and velocity.  She avoids turning her head when walking; when asked why, she denies pain but reports instability, without falls.

Balance:

Romberg with eyes closed 30 seconds.

Sharpened Romberg with eyes open 20 seconds, eyes closed 4 seconds.

mCTSIB: 30 seconds all conditions except eyes closed on foam, 25 seconds with increased sway.

SLS eyes open 30 seconds bilaterally, but eyes closed 15 seconds Left, 20 seconds right; both times decrease to 5 seconds if head held in right rotation.

Flexibility:

Thomas test positive bilaterally.  Dorsiflexion 7° bilaterally.

Positional Testing:

Left Dix-Hallpike negative.

Right Dix-Hallpike reproduces vertigo and upbeating, right torsional nystagmus of short duration.

Roll Test (Horizontal canals) negative.

QUESTIONS:

1) What is your diagnosis?

2) What would be your initial treatment intervention?

3) What is the patient’s prognosis?

References

Froehling DA, Silverstein MD, Mohr DN, Beatty CW. Does this dizzy patient have a serious form of vertigo? JAMA: Journal of the American Medical Association 1994: 271(5): 385-388.

May S, Withers S, Reeve S, Greasley A. Limited clinical reasoning skills used by novice physiotherapists when involved in the assessment and management of patients with shoulder problems: A qualitative study. J Man Manip Ther 2010: 18(2): 84-88.

Pelaccia T, Tardif J, Triby E, Charlin B. An analysis of clinical reasoning through a recent and comprehensive approach: The dual-process theory. Medical Education Online 2011: 16(5890).

Stiell IG, et al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA 2001: 286(15): 1841-1848.

And the answer is…

INTRODUCTION: Well, we had great participation to the first post in this series! Now, are you ready to find out what the results of the poll were, and take the next step on the journey of treating this 67-year-old patient? We look forward to your comments on this follow-up post!

Note: You can be automatically notified of  new postings and comments by clicking the “Follow” button on the lower right end of your screen and/or checking “Notify me of comments” when you enter your comment.

Without further ado, I give you Dr. Landel!

Marilyn Pink, PT, Ph.D

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Rob Landel

Guest blogger Rob Landel, PT, DPT, OCS, CSCS, FAPTA

Thank you all for your thoughtful answers!

Here’s how you voted:

And while an argument could be made for all of these possible answers being correct, the answer that places the PT in the most responsible role is #D (“Consider what diagnoses might be causing her symptoms”). Surprised? Here’s the rationale:

Answer A could be appropriate and naturally is the safe course of action. However, for the sake of argument (and this blog!), could a physical therapist proceed with further investigations to determine what the problem is? Could activating the ERS be an overreaction considering her response after the dizzy spell passes? (please feel free to submit your thoughts on this!)

While answer B is correct,it is likely the physician will ask for more information; having immediately made the call, you won’t have any answers to give. In addition, proceeding in this manner has the PT working in the role of a technician rather than as a contributing member of the healthcare team.

 Answer C will provide the PT with more information, so could also be considered correct. But what will guide the PT as to what questions should be asked? The most organized method of questioning will be be based on a differential diagnostic process, using a list of hypothetical diagnoses to guide which questions should be asked.

I would argue, supported in the medical education literature, e.g. (May et al., 2010; Pelaccia et al., 2011) that even a novice clinician would intuitively have a few possible diagnoses in mind, and that these would influence which questions he or she asks and follows up on. The more experienced or expert clinician will follow the intuitive thought process with a more analytical one, likely resulting in a greater number of possible diagnoses (Pelaccia et al., 2011). Therefore, Answer D is the best answer, and you are likely doing it already even if you aren’t aware of it!

Do you agree with this reasoning, or do you have some other take? I’d love to hear back on the above.

And now, onto the next chapter in our case:

Further Subjective Findings

You assure her that dizziness is a condition that many PT’s encounter in their patients and treat effectively. She reports an initial onset of dizziness 7 months ago while playing in the pool with her grandchildren.  She reports the acute symptoms lasted 2-3 minutes, and then gradually subsided although she felt nauseated for an hour or more afterwards. She denies trauma to her head or neck at that time, but she does report occasional neck pain. Since then she has had two more episodes of dizziness that she describes as spinning, both of short duration (a few minutes) and perhaps associated with looking up, bending down to a low cupboard, lying down, and turning over in bed. She also feels generally unsteady and off balance. Because of these problems she has difficulty caring for her grandchildren. Since the MVA 4 weeks ago she has had an increase in the severity and frequency of her spinning episodes.

She is retired and lives with her husband in a single story home. Past medical history is significant for hypertension, hearing loss in her left ear that she describes as “minimal,” and a 15 year history of intermittent neck pain. Medications include Lasix and a potassium supplement, and a multi-vitamin. She takes Advil for her headaches prn and that usually helps.

I’ll leave you with the following questions:

  1. What are the most likely causes of the patient’s dizziness?  Support your choices with the known facts.
  2. Are there any pathologies that may be causing her symptoms that are concerning to you (even if they aren’t likely causes)? If so what are they, and how would they present?
  3. What questions would you ask of your patient, and why?
  4. What physical examination would you perform at the initial evaluation?  Prioritize your tests and measures, and justify why you would choose to do each test.

And I look forward to your comments!

When Orthopedic and Vestibular Physical Therapy Meet Neck Pain, Headaches and Dizziness

INTRODUCTION, by Marilyn Pink, PT, Ph.D: I have known and admired Dr. Landel for many years as a top orthopedic clinician, researcher and educator, recognized with numerous awards. Just this year, Dr. Landel was named a Catherine Worthingham APTA Fellow, the highest honor among APTA membership categories. So, we are particularly pleased to bring you the first on a series of posts by Rob and encourage you to comment & pose questions. This is an opportunity to interact with a real luminary in PT!

An evolving patient presentation: what else is going on here?

Rob Landelby guest blogger, Rob Landel, PT, DPT, OCS, CSCS, FAPTA

You are a physical therapist treating a 67-year-old female accounts payable administrator for the past 2 weeks for neck pain and headaches (HA).

Her neck pain is bilateral, localized to the suboccipital region, without radiation into either upper or lower extremitiy. Her headaches are mainly in her bilateral forehead region. Both her neck pain and HA began after a motor vehicle accident (MVA) 4 weeks ago but both are improving since starting PT with you.

Radiographs taken the day of the MVA were negative and the MD referred her to PT for a diagnosis of “muscle strain.” Your plan of care has been to address the impairments associated with soft tissue damage in the cervical spine following her whiplash injury: early immobilization and inflammation-reducing modalities followed by progressive AROM as tolerated, gradually introducing gentle PROM including manual therapy, and postural re-education. You have just recently started working on improving her muscle function through exercise.

Today as you begin her treatment when she goes to lie down she grabs the plinth for several seconds, shutting her eyes and swaying slightly, before gradually relaxing and proceeding to assume a supine position. She opens her eyes, notes you looking at her, smiles grimly and sheepishly apologizes. When you question what just happened, she says she’s been getting dizzy spells for the past several days. She hadn’t mentioned it to you since you were treating her for her neck pain, not for dizziness.

How did you vote?  

In our next blog post I will provide our own input, but for now I invite you to not only vote, but type in your comments to expand on WHY you picked that particular answer.

I look forward to hearing from you!

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