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Clinical Reasoning Case Study
Male with right sided neck pain with right sided jaw paratheisa
This essay will focus on a case study of a male patient experiencing right sided neck pain with right sided jaw parathesia. The author hopes to describe the patient’s journey from initial assessment to discharge. The author hopes to detail how a clinical hypothesis was generated. This hypothesis will be backed up by sound clinical reasoning skills and current evidence based research.
History of Presenting Condition (HPC):
A fifty four year old male presented to the clinic complaining of right sided neck pain with right jaw parathesia. Patient described a long history (> 10 years) of neck “stiffness” and upper trapezius “tightness” and “tiredness” (Pain A). It was always of insidious onset. He reports these episodes would come and go but would always settle down. He never received any physical treatment for this pain. He felt heat therapy helped settled it down. However in the last 4 weeks he felt Pain A again. This time it didn’t settled down and he felt it get progressively worse. Then in the last 4 days he started to experience a constant numbness around his left jaw area (Pain B).
The Patient described Pain A as:
A Constant pain but the intensity could change. He described it as a 9/10 on the Numerical Pain Rating Scale (NPRS) (Williamson & Hoggart 2005) at its worst. He described it as 4/10 on NPRS at its best. He would occasionally get a sharp shooting pain. He also reported hearing clicks. Turning to his head to left, extending backwards and moving in bed where his mot aggravating factors. He felt some relief when he was on the move and found walking beneficial.
The 24 hour for Pain A was as follows:
AM- Increase in the pain (8/10) but would ease by the time he had his breakfast (5/10)
Day- Could get worse or better depending on what he did but overall a little better
Night- At its worst (9/10) and would wake him from his sleep
The patient described Pain B as:
A Constant numbness with no change. Even when Pain A would ease Pain B would stay the same. There was no 24 hour pattern.
The patient reported no apparent red flags. He reported no drop attacks, dizziness, dysphasis, dysarthia or diplopia (Considered as the 5 D’s). He reported no nausea, ipsilateral numbness or nystagmus (3 N’s). He reported no ataxia.
Past Medical History:
Hypertension for which he takes Aldactone.
High Cholesterol for which he takes Mevacor.
No cancer, no unexplained weight loss/gain, no steroids, no epilepsy, no respiratory disease.
Patient reported he has worked as a civil servant in the tax department for almost 23 years. He enjoys walking and bowls. He reports no apparent yellow flags.
Clinical Reasoning from the Subjective Interview:
A key evaluation theory proposed by Maitland () is the acronym “SIN” (severity, irritability, nature) which is used to judge a patient’s condition. Form the subjective interview the author concluded that the patients:
Severity-moderate to high
Nature: Mechanical & Inflammatory
Taking into the account the patient’s pain location and main aggravating factors of compression( extension and left rotation), the facets joints of the cervical spine (C-Spine) where considered a possible source of the patients pain. Pain referral patterns of the cervical spine facets researched by Cooper et al (2007) back this hypothesis up. When the 24hour pattern is analysed, it indicates a degenerative pattern which could further effect the nerve roots in the spine (Penning 1992). The patient does report his symptoms are worse at night and this may indicate nerve ischemia (Glifford 2001). When further analysed, the increase in night pain was linked to the mechanical movement of turning in bed. The author also felt that joint pain would mostly likely be accompanied by muscle dysfunction. It is well highlighted that muscle imbalance can develop after the onset of pain and is common in chronic pain syndromes (Nijs et al 2012, Falla et al 2004).
Pain B (jaw paraesthesia) was insidious after onset of Pain A. This could signify a relationship between the Pain A and Pain B. Trigeminal neuralgia, following a compromise at the left upper cervical facet joint was hypothesised. Possible other causes of trigeminal neuralgia could not be fully ruled out either.
Clinically reasoning form the subjective interview the author developed the following working hypothesis:
- Arthrogenic: (50%) C0-C3, C4/C5, C5/C6, Cx/Tx junction
- Neurogenic: (30%) Trigeminal neuralgia? Cervical root compromise
- Myogenic: (20%) Cervical Muscle imbalance
This working hypothesis made the author aware of “MUST, SHOULD,COULD” protocol for the objective examination and is shown in the diagram below:
Active Cx movements
Active Tx movements
Cx PPIVMS / PAIVMS
Tx PPIVM / PAIVMS
Cx / Tx PPIVM / PAIVMS
Shoulder girdle(Press test)
The patient presented with a forward head posture, increased thoracic kyphosis and increased anterior pelvic tilt. He was side flexed to the left at the Cx spine and side flexed to the left at the Tx. The cervical assessment findings are shown in the diagram below:
As shown in the diagram, the objective assessment found a hypomobile C2/C3 facet joint with reproduction of the jaw parartheisa. The Cx/Tx junction was also found to be hypomobile.
The patient was also found to overweight weighing 113 kilograms. The cranio cervical flexion test (CFFT) found excessive recruitment of the sternomastoid and scalene muscles. The ULTT appeared normal for left and right with elbow extension at -20 degrees elbow the patient reported a cubital fossa pull. There was no increase with Cx side flexion. The patient was also found to overweight weighing 113 kilograms.
Clinical Reasoning from the Objective Examination:
The patients forward head posture combined with his left sided head tilt may be a causative factor predisposing him to facet joint problems. A major nerve root compression could not be excluded either. Combined extension & rotation to the same side is the main indicator of nerve root compromise. The patient became more aware of his jaw paratheisia with palpation of the C2/C3 facet joint. This supports the initial hypothesis that the patients pain was of a cervical origin. The neural exam appeared normal. However the length and history of his his cervical discomfort does indicate some centrally sensation.However weighing up the evidence the author felt his symptoms followed a more mechanical and peripheral nociceptive source keeping inline with degernation of the facet joints.
Physiotherapists rely greatly on the use of manual and diagnostic tests and manual to achieve an accurate diagnosis. Unfortunately there is a real lack of quality evidence to back up most of the
However the objective findings, in conjunction with the entire assessment, helped support the original hypothesis of a strong arthrogenic component. This cluster-examination process is the only way to enhance an accurate diagnosis.
This helped to confirm the SIN factor: S-Mild/Moderate
N- Mechincal (80%) Inflammatory (20%)
Based on the findings from the objective exam, the author decided that the trament plan would revolve around
(b) Manual Therapy to the sympotomativ joints
(c) Address poor muscle control and postural awareness
The first treatment session focused on Posterior-to-Anterior Glides Grade 3 which were applied unilateral on the right side at C2/C3. The desired effects of this manual therapy was to influence nocicieptive barrage into the dorsal horn and facilitate pain suppression mechanisms from the brain ( Gross et al 2008, Vernon et al 2007). Coppieters et al (2003) found it to help and maintain neural tissue health. Manual therapy was also found to decrease the activity of the superficial neck flexors (Sterling et al 2001).
Much research has highlighted that disturbed muscle patterns can still linger despite resolution of pain. If these patterns are not addressed properly the problem can return. A biofeedback was machine was used to improve the cooradination of his muscle activity ( Hodges 2011, Panajabi 1992).
Follow up treatment
The treatment progression focused on combined PPIVMS and PAIVMS
After 4th session
Patient reported full movment of the cervical spine, no pararthesia, no discomfort during the day but was still experiencing pain upon turning in bed.
The aurthor admits he did not spend enough time on educatuion
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