of Spurling’s test, upper limb tension test, distraction test, and cervical rotation less than 60 degrees to the left. Another diagnosis to consider is cervical facet joint dysfunction. A rear-end collision can cause accelerated cervical extension, which, in turn, can lead to facet joint inflammation and pain. As discussed above, facet joint irritation can cause referred pain to the shoulder. This diagnosis can be confirmed by applying a postero–anterior force to each of the left-sided facet joints (positive findings included reproduction of client’s pain and motion restriction), assessment of cervical spine range of motion, and the extension–rotation test. Finally, the client does report involvement of the neck muscles, which is consistent with myofascial or mechanical neck pain conditions. The assessing clinician should assess the left scales, levator scapula, and upper trapezius muscles for tenderness and loss of flexibility. Involvement of the facet joints and soft tissue is typical with a diagnosis of whiplash-associated disorder, although using the diagnoses of left-sided cervical joint dysfunction with left-sided soft tissue involvement is more specific. Case Study: Charles O’Connor Mr. O’Connor is a 62-year-old retired male who presents to physical therapy via referral from his primary care physician to address left temporomandibular joint pain. The client reports that he has constant pain in the left jaw that can get severe at times. He cannot recall any specific trauma or precipitating incident. The pain has been present for about one month. It is worse with turning his head and while sitting for longer periods (driving, reading). He also has pain when he is active, such as when doing yard work and playing golf. His medical history is significant for lower cervical spinal fusion (client does not recall specific level(s)) several years ago. Upon further questioning, the client recalls that a few months ago, he had left-sided head and neck pain that he localizes to the suboccipital, temporal, and mastoid areas. He considers these symptoms minor compared to his main complaint of left jaw pain. Question What might differential diagnosis look like in this case? Discussion The logical initial step, given the client’s complaints, in differential diagnosis for this client is examination of the left temporomandibular joint. This showed that all active motions of the joint—opening and closing the mouth, jaw protrusion and retrusion—were normal, symmetrical, and pain free. He did not have tenderness at the temporomandibular joint, nor did he have tenderness in the masseter or temporalis muscles. The assessing clinician ruled out temporomandibular joint involvement at this point. The next logical step in differential diagnosis is examination of the cervical spine. Examination revealed the following positive findings: Limited motion at C0–C1 (cervical flexion/head nodding) and limited motion at C1–C2 (flexion–rotation test), both left greater than right. The client exhibited a mild forward head posture with tenderness in the suboccipital muscles. Myotome and dermatome testing in the upper extremities was negative, and bilateral bicep, triceps, and brachioradialis testing was normal. Testing for strength/endurance of the deep neck flexor muscles via the craniocervical flexion test was positive. Keeping in mind that there is a close relationship between temporomandibular joint disorders and the upper cervical spine, the assessing clinician concluded that the client’s jaw symptoms were related to dysfunction of the upper cervical spine (suboccipital muscle tenderness, forward head posture, limited upper cervical spine motion, weak deep neck flexor muscles) and designed an appropriate treatment plan.
Case Study: Mandy Mason Ms. Mason is a 49-year-old female who presents to physical therapy via direct access with complaints of bilateral neck, shoulder, and upper back pain. She does not recall any specific cause of these symptoms but rather states that this is a chronic problem that comes and goes every few years. In the past she has tried physical therapy but states it only helped for an hour or two after each visit. The client’s medical history is significant for hypothyroidism, asthma, depression, and bipolar disorder. She describes her current pain as constant at 7/10 and says that it gets worse at the end of her workday so that it is “excruciating” by the time she leaves work. When she leaves her job as a social worker, she goes home and immediately goes to bed. She describes her job as stressful and overwhelming. She is not able to name any position, besides lying down, that alleviates her pain. Examination revealed full bilateral active upper extremity range of motion, although the client states that all the movements increased the pain in her upper back and neck. Upper extremity strength testing was confounded by the elicitation of pain. Cervical side bend and rotation were moderately limited in both directions and painful. She demonstrated a slouched posture but was able to correct it with cuing, stating that “my other physical therapist taught me good posture” then adding “but it hurts to sit up straight.” Assessment of facet joint mobility revealed mildly decreased upper cervical facet joint mobility and moderately limited upper thoracic joint motion with pain at all cervical and upper thoracic levels. Acute muscle tenderness and mild to moderate tightness was noted in the bilateral upper trapezius, levator scapula, scalene, and sternocleidomastoid muscles. Questions What yellow (orange) flags are present? Given the findings listed above, what diagnosis would you assign this patient? What further tests/screening might be helpful? Is referral to another healthcare provider indicated? Discussion One yellow flag is the client’s high level of constant pain and the description of her end-of-day pain as excruciating. Other yellow flags are not finding any position that relieves her pain, avoiding activity by going to bed, and hypervigilance about her pain. An orange flag is the diagnosis of depression. Referral to a mental health provider to address both depression and stress management may be appropriate. The client’s pain response to all movements and touch is a sign of central sensitization, which should be included in the diagnosis. One additional screening tool that may be helpful with this client is the Central Sensitization Inventory. Although a definite diagnosis is difficult to arrive at due to the client’s exaggerated pain response, a diagnosis of mechanical neck pain with central sensitization seems to fit. A plan of care that follows this diagnosis might logically include pain neuroscience education as well as stretching exercises and posture education. Case Study: Laura Long (Implicit Bias) Ms. Long was referred to home care physical therapy after cervical spine decompression and fusion related to a diagnosis of cervical myelopathy. The client’s home is in a trailer park and is in disarray, much of it related to her difficulty with managing her home due to her neck condition. The assessing physical therapist is uncomfortable in the client’s home. After assessing the client, the therapist decides the client would only need a minimal number of visits. How is this a case of implicit bias? In this case, the number of visits planned for this client was influenced by the client’s socioeconomic status (trailer park), not by her physical needs.
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Book Code: PTNY1024
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