Solve this Case

[wrennywren]

I'm scared. I have no idea what half that crap means.

Good thing I start school in 4 weeks!

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[jesspt]

I hate to post this, because I don't have the reference. But I remember reading something by Stanley Paris, or maybe he just said it, but basically the point is that most CS facet capsules do not become compressed during end ROM, but likely through mid-ROM, and many times c/o pain will be associated w/ mid ROM.

Thoughts here?

I thought this might be where you were headed. Paris is one of the only manual therapy folks who discusses synovial fold impingement as a source of pain. Now, Dr. Paris is a brilliant man, so I am sure he has at least a cadaveric study to back this up, but I would wager that is about it.

So, I would say that the synovial tissue is a possible pain generator, but it is no more likely to cause pain than many other structures that are present in the cervical spine. So, is it possible that the disc could be causing pain? Certainly there are likely to be shearing forces placed across it as the patient moves from a flexed position to neutral. Is it more likely to be the culprit that the synovial fold? Maybe. Maybe not.

This is the problem with chasing a specific tissue and trying to label it the pain generator. It is nearly impossible in many instances. And, it may lead you down an incorrect treatment path. You'll also tend to look a fool if you talk about synovial fold impingement with many physicians as they are likely aware of the data which supports the extreme difficulty in ascertaining a specific tissue as the one source of a patient's spinal symptoms.

You're far better off to look a combinations of symptoms and physical findings and use those things to help drive your treatment/interventions.

If therapists feel the need/desire to be so beholden to the patho-anatomical model and biomechanical approach, they would do well to remember that the biomechanical approach is a model, which in some instances helps to explain our observations with patients, and that what is actually happening structurally within the patient may not resemble our model at all. Jim Meadows from the North American Institute of Orthopaedic Manual Therapy (www.naiomt.com) gives a great lecture about this, warning our profession about the pitfalls of speaking about things such as "facet joint subluxation", "locked facet joint", "segmental hypermobility/instability" as though these things can actually be determined with acceptable accuracy through manual assessment. It cannot be done, and there is a load of research that shows to poor accuracy of these assessment techniques.

Does that mean that the model can't be used to help patients? Of course not, and it has been used for decades to great success for some practitioners. But, we need to be aware of the pitfalls of the approach as well.

 

[rcheeley]

Thanks for the input Jess, and great information. You're completely right about everything you just said...

However I think you're missing the point of this "exercise." Yes we're looking at 1 specific case, but the purpose of what I was wanting, was just discussion. For example, if person A said "well what about this....based off this information" and then there was discussion about why or why not it could be this. Then person B said "well what about this...based off this information" and then there was discussion about why or why not it could be this. I wasn't really looking for a specific answer or for any particular "correct answer." I was just looking for answers...

As you said, who the hell knows what could be causing this persons pain. It could be a facet issue, it could be a disc issue, could be some sort of bony abnormality that is causing stenotic like symptoms (however not likely due to location of symptoms); the point is it could be a million different things. I just wanted discussion on it. However, typically when you treat someone, you have some type of hypothesis as to why they are, the way they are. So when you have this hypothesis, you're treatment is focused around this and it either works, or it doesn't work. If it works, then what do you know, you were right, and you "fixed" this person. If you were wrong, then you change your approach.

The point I was getting at, is I just wanted discussion. I don't want you to solve this riddle, fix this person, or anything like that, I just wanted discussion. I see now I was wrong in the titling of this thread, as I should have just put "Lets discuss this Case Study" instead of "Solve this Case." I was expecting 1) discussion on differential diagnosis, and then 2) discussion on possible treatment ideas. We're obviously having a hard time getting past part 1.

I'm not trying to be an "ass" here, I just feel like there's a communication issue, as it seems we're not on the same page with this thing. I do appreciate all of your information, as you seem to have a lot of very useful information to present to everyone. I wish there were more that would enlighten us w/ their knowledge, but as you said in a previous post about McKenzie, there probably aren't very many clinicians on here, more students.

My apologies for not being more clear and organized before I started this thread. I just thought it was an interesting case that could be shared w/ others.

I thought this might be where you were headed. Paris is one of the only manual therapy folks who discusses synovial fold impingement as a source of pain. Now, Dr. Paris is a brilliant man, so I am sure he has at least a cadaveric study to back this up, but I would wager that is about it.

So, I would say that the synovial tissue is a possible pain generator, but it is no more likely to cause pain than many other structures that are present in the cervical spine. So, is it possible that the disc could be causing pain? Certainly there are likely to be shearing forces placed across it as the patient moves from a flexed position to neutral. Is it more likely to be the culprit that the synovial fold? Maybe. Maybe not.

This is the problem with chasing a specific tissue and trying to label it the pain generator. It is nearly impossible in many instances. And, it may lead you down an incorrect treatment path. You'll also tend to look a fool if you talk about synovial fold impingement with many physicians as they are likely aware of the data which supports the extreme difficulty in ascertaining a specific tissue as the one source of a patient's spinal symptoms.

You're far better off to look a combinations of symptoms and physical findings and use those things to help drive your treatment/interventions.

If therapists feel the need/desire to be so beholden to the patho-anatomical model and biomechanical approach, they would do well to remember that the biomechanical approach is a model, which in some instances helps to explain our observations with patients, and that what is actually happening structurally within the patient may not resemble our model at all. Jim Meadows from the North American Institute of Orthopaedic Manual Therapy (www.naiomt.com) gives a great lecture about this, warning our profession about the pitfalls of speaking about things such as "facet joint subluxation", "locked facet joint", "segmental hypermobility/instability" as though these things can actually be determined with acceptable accuracy through manual assessment. It cannot be done, and there is a load of research that shows to poor accuracy of these assessment techniques.

Does that mean that the model can't be used to help patients? Of course not, and it has been used for decades to great success for some practitioners. But, we need to be aware of the pitfalls of the approach as well.

 

[Akiramay]

With that being said I'd love more 'Case Study Discussions'. I'm finding it very helpful...and fun!

 

[Danae00]

Rcheeley, thanks for posting this discussion. And also wanted to thank you for this clarifying post of what you were hoping to accomplish. I admit got a bit confused part way through the thread what exactly it was you were looking for.

If I understand correctly what you were hoping for was us trying to narrow down multitude of possibilities into a few potential differential diagnoses based on the way the patient is presenting. Not necessarily coming up with the "one" right answer, but just wanting the clinical reasoning to justify the answers we did come up with. And this was not an exercise so much to emulate how we would actually diagnose the patient "in real life" but rather just as an academic exercise to see how specific we can go. Or am I completely off base?

Sorry I didn't add much to the discussion, but i think Jess pretty much said everything I would have with her post on the 20th.

Hope you will post another one someday! I will try to post something myself, but I think I will need some inspiration on one of my placements or in the clinic to come up with a plausible case.

Thanks for the input Jess, and great information. You're completely right about everything you just said...

However I think you're missing the point of this "exercise." Yes we're looking at 1 specific case, but the purpose of what I was wanting, was just discussion. For example, if person A said "well what about this....based off this information" and then there was discussion about why or why not it could be this. Then person B said "well what about this...based off this information" and then there was discussion about why or why not it could be this. I wasn't really looking for a specific answer or for any particular "correct answer." I was just looking for answers...

As you said, who the hell knows what could be causing this persons pain. It could be a facet issue, it could be a disc issue, could be some sort of bony abnormality that is causing stenotic like symptoms (however not likely due to location of symptoms); the point is it could be a million different things. I just wanted discussion on it. However, typically when you treat someone, you have some type of hypothesis as to why they are, the way they are. So when you have this hypothesis, you're treatment is focused around this and it either works, or it doesn't work. If it works, then what do you know, you were right, and you "fixed" this person. If you were wrong, then you change your approach.

The point I was getting at, is I just wanted discussion. I don't want you to solve this riddle, fix this person, or anything like that, I just wanted discussion. I see now I was wrong in the titling of this thread, as I should have just put "Lets discuss this Case Study" instead of "Solve this Case." I was expecting 1) discussion on differential diagnosis, and then 2) discussion on possible treatment ideas. We're obviously having a hard time getting past part 1.

I'm not trying to be an "ass" here, I just feel like there's a communication issue, as it seems we're not on the same page with this thing. I do appreciate all of your information, as you seem to have a lot of very useful information to present to everyone. I wish there were more that would enlighten us w/ their knowledge, but as you said in a previous post about McKenzie, there probably aren't very many clinicians on here, more students.

My apologies for not being more clear and organized before I started this thread. I just thought it was an interesting case that could be shared w/ others.

 

[rcheeley]

Yes, that's what I was looking for. And by the way, the name's Ryan.

Rcheeley, thanks for posting this discussion. And also wanted to thank you for this clarifying post of what you were hoping to accomplish. I admit got a bit confused part way through the thread what exactly it was you were looking for.

If I understand correctly what you were hoping for was us trying to narrow down multitude of possibilities into a few potential differential diagnoses based on the way the patient is presenting. Not necessarily coming up with the "one" right answer, but just wanting the clinical reasoning to justify the answers we did come up with. And this was not an exercise so much to emulate how we would actually diagnose the patient "in real life" but rather just as an academic exercise to see how specific we can go. Or am I completely off base?

Sorry I didn't add much to the discussion, but i think Jess pretty much said everything I would have with her post on the 20th.

Hope you will post another one someday! I will try to post something myself, but I think I will need some inspiration on one of my placements or in the clinic to come up with a plausible case.

 

[jesspt]

However I think you're missing the point of this "exercise." Yes we're looking at 1 specific case, but the purpose of what I was wanting, was just discussion. For example, if person A said "well what about this....based off this information" and then there was discussion about why or why not it could be this. Then person B said "well what about this...based off this information" and then there was discussion about why or why not it could be this. I wasn't really looking for a specific answer or for any particular "correct answer." I was just looking for answers...

I understood the point of the exercise. And, if you'll look at post #25, you can see that I began to list my problem solving up to that point. Perhaps we need to outline a typical differential diagnostic process in order to make everyone more clear on the desired outcome.

However, typically when you treat someone, you have some type of hypothesis as to why they are, the way they are. So when you have this hypothesis, you're treatment is focused around this and it either works, or it doesn't work. If it works, then what do you know, you were right, and you "fixed" this person. If you were wrong, then you change your approach.

Absolutely. I use the Hypothesis Oriented Algorithm for Clinicians (HOAC, Rothstein et al) as the basis for my clinical decision making. You may be familiar, but I am not sure that USA uses this in their treatment framework. In essence, it requires a clinician to establish a preliminary hypothesis prior to even taking a subjective history. That hypothesis is then refined throughout the subjective and objective portions of the examination. It is this refined hypothesis that drives your treatment interventions. I think you and I are on the same page so far.

Where I think our approaches differ, particularly in this case, is the latter portion of your statement - "If it works, then what do you know, you were right, and you "fixed" this person. If you were wrong, then you change your approach." So, in this scenario, if your hypothesis was that the patient's symptoms were caused by synovial fold entrapment, and you proceeded with whatever manual therapy intervention you chose, and the patient got better, you seem to think that this validates your initial hypothesis. That's only true when we have a reliable and valid test or assessment technique for the given condition. Which, in the case of synovial fold entrapment, we don't. I think it is faulty logic to make the leap it sounds like you are ready to make just because symptoms are improved by the intervention you chose, however happy you have just made your patient.

For example, my brother-in-law just called me this morning with left sided intra-scapular pain that presented much like the case you initially described, although he had palpable muscle spasms throughout the sternocliedomastoid and cervical paravertebral muscles as well as symptom reproduction with a (L) sided unilateral P-A over the mid cervical spine. My hypothesis was acute, mechanical (L) sided cervico-thoracic pain. I treated him with a series of manual therapy interventions as well as pain-free AROM exercises and he regained full (L) cervical rotation and sidebending. The results of that treatment don't validate my hypothesis, but they do validate the interventions I selected.

The point I was getting at, is I just wanted discussion. I don't want you to solve this riddle, fix this person, or anything like that, I just wanted discussion. I see now I was wrong in the titling of this thread, as I should have just put "Lets discuss this Case Study" instead of "Solve this Case." I was expecting 1) discussion on differential diagnosis, and then 2) discussion on possible treatment ideas. We're obviously having a hard time getting past part 1.

I know you wanted discussion, but you seemed to get fixated on a particular diagnosis that is rare, if it even exists. Then, you stated it was your hypothesis without any support, other than Paris' opinion and what I would consider a correct statement that the facet joint surfaces were unlikely to be compressed with the ROM the patient had available. Gwendolyn Jull has said that when one hears hooves, they should first think horses, not zebras. I think we latched onto a zebra.

Also, I don't think we got stuck on differential diagnosis. Here's what I consider the steps in differential diagnosis. Others please chime in if you think I have omitted anything:
1. Screen for red flags to help determine if the patient's symptoms are musculoskeletal or systemic/visceral. If systemic or visceral, refer out.
2. If symptoms are musculoskeletal, determine if it is possible PT could do them harm (such as a missed dens fracture after MVA) and if so, refer out.
3. Use symptom characteristics such as severity, irritability, nature, etc. to help refine hypothesis
4. Perform an exam using test with good specificity/sensitivity, +/- likelihood ratios,etc. whenever possible to help rule in or rule out teh primary hypothesis.
5. Use that hypothesis to drive the interventions I will treat the patient with.

I am not trying to be inflammatory, and I admire your intentions with this thread, but I think we can refine our process to improve future problem solving exercises.

 

[rcheeley]

Recently published article on facet related pain/symptoms.

http://www.ncbi.nlm.nih.gov/pubmed/21269888

 

[jesspt]

Recently published article on facet related pain/symptoms.

http://www.ncbi.nlm.nih.gov/pubmed/21269888

Not exactly rousing support for our biomechanical model, is it?

 

[rcheeley]

Not exactly rousing support for our biomechanical model, is it?

No it's not, just wanted to post. I came across it in another thread in either the Neuro board or the Pain board, thought it was interesting. Many of the Physicians were discussing their treatment phylosophies regarding "facet syndrome."