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Outpatient Physical Therapy for a Patient with Cervical And OUTPATIENT PHYSICAL THERAPY FOR A PATIENT WITH CERVICAL AND THORACIC PAIN A Doctoral Project A Comprehensive Case Analysis Presented to the faculty of the Department of Physical Therapy California State University, Sacramento Submitted in partial satisfaction of the requirements for the degree of DOCTOR OF PHYSICAL THERAPY by Jared Michael Mason SUMMER 2015 © 2015 Jared Michael Mason ALL RIGHTS RESERVED ii OUTPATIENT PHYSICAL THERAPY FOR A PATIENT WITH CERVICAL AND THORACIC PAIN A Project by Jared Michael Mason Approved by: ______________________________________________, Committee Chair Rafael Escamilla Ph. D, P.T., C.S.C.S. __________________________________, First Reader Creed Larrucea PT, DPT, ECS __________________________________, Second Reader Edward Barakatt, PT, PhD ____________________________ Date iii Student: Jared Michael Mason I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project. _________________________ , Department Chair ______________ Dr. Edward Barakatt Date Department of Physical Therapy iv Abstract of OUTPATIENT PHYSICAL THERAPY FOR A PATIENT WITH CERVICAL AND THORACIC PAIN by Jared Michael Mason A patient with cervical and thoracic pain was seen for student physical therapy treatment for 6 visits from 3/12/14 to 4/30/14 at an outpatient clinic under the supervision of a licensed physical therapist. The patient was evaluated at the initial encounter with range of motion (ROM), cervical flexion endurance test, Kibler scapular retraction test, side plank endurance test, Beiring Sorensen test, and the Neck Disability Index, and a plan of care was established. Main goals for the patient were to restore thoracic ROM to within normal limits (WNLs), improve muscular endurance and strength of the core, spine extensors, scapula depressors, and retractors, improve ability to perform student responsibilities (computer work, carrying a backpack, sitting at desk for prolonged periods) without complaints of pain, return to archery, playing guitar, and workout program. Main interventions used were task-specific strength and endurance training, manual therapy, ergonomic training, home exercises program, and patient education. The patient achieved the following goals: thoracic ROM increased to WNLs, reached normal limits on all endurance outcome measures, achieved unrestricted sitting endurance, achieved unrestricted lifting/carrying loads, and the patient was able to return to archery and guitar participation. v The patient was discharged to his current residence with an independent self-management program incorporating gym-based training, a graduated rehabilitation program, and a return to sport outline. ___________________________________________ Rafael Escamilla Ph. D, P.T., C.S.C.S., Committee Chair _______________________ Date vi ACKNOWLEDGEMENTS To my lovely wife and best friend Sommer, for her steadfast love encouragement, and support. To my parents, Karl and Mary Mason, for their love and support. To the faculty at Sacramento state PT program with special thanks to Edward Barakatt, Rafael Escamilla, and Creed. vii TABLE OF CONTENTS Page Acknowledgements ................................................................................................................. vii List of Tables ........................................................................................................................... ix Chapter 1. GENERAL BACKGROUND .................................................................................... 1 2. CASE BACKGROUND DATA ................................................................................ 4 3. EXAMINATION – TESTS AND MEASURES........................................................ 6 4. EVALUATION........................................................................................................ 13 5. PLAN OF CARE – GOALS AND INTERVENTIONS .......................................... 15 6. OUTCOMES............................................................................................................ 27 7. DISCUSSION .......................................................................................................... 30 References ............................................................................................................................. 34 viii LIST OF TABLES Tables Page 1. Examination Data………………………………… . .………………………………. 11 2. Plan of Care……………………………….… .............. ……………………………. 15 3. Outcomes……………………………….……… .............. …………………………. 27 ix 1 Chapter 1 GENERAL BACKGROUND Neck pain is a common complaint in society. Neck pain can be due to multiple conditions, including disc pathology, facet/joint dysfunction, nerve root irritation/impingement/dysfunction, myofascial pain syndrome, muscular dysfunction, and/or abnormal posture.1 The common causes include poor posture during occupational or recreational activities, and osteoarthritis. Rarely, neck pain can be a symptom of a more serious problem.1 It is estimated that 22-70% of the population will have neck pain in their life time. It is also estimated that 10-20% of the population has neck pain at any given time and 54% have experienced neck pain within the past 6 months.2 Neck pain is most common in women around 50 years old. Recurrence rates for cervical pain is estimated to be approximately 30%, and 44% of all cases become chronic in nature. It has been found that approximately 42% of workers will miss 1 week per year due to neck pain, with 26% of such cases experiencing recurrence within 1 year.3 Risk factors for developing cervical pain are as follows: age greater than 40 years, low back pain, long history of neck pain, bicycling as regular activity, loss of strength in hands, worrisome attitude, poor quality of life, and low vitality.1,2 Prognosis of recovery is moderately high for all conditions mentioned except for whiplash, which has a poorer prognosis. For return to pre-injury activities, it is important to return patients to normal routine/activities.1 Physical therapy interventions, including manual therapy, exercises, and patient education, have been shown to be effective at improving a patient’s prognosis, with a growing interest in manipulations to the cervical and/or thoracic spine area as a form of treatment.4,5,6 Lower back pain (lumbar region) and cervical pain have received much attention due to their disabling nature. However, upper back pain (thoracic region) requires equal 2 examination due to its ability to cause disability. In chronic spine pain, diagnostic and therapeutic challenges are present, including multiple pain sources, overlapping clinical features (features that would lead to no specific diagnosis), and nonspecific radiological findings ( abnormal image findings doesn’t correlate with clinic symptoms) .7 Thoracic spine pain in particular may arise from a number of sources, including thoracic and/or cervical spinal structures, the thorax, or the gastrointestinal, cardiopulmonary, or renal systems.8 The thoracic spine is known as a common site for inflammatory, degenerative, metabolic, infective, and neoplastic conditions.9 The clinical terms upper back pain, middle back pain, and thoracic back pain all refer to the region of the thoracic vertebrae, which are between the bottom of the neck and top of the lumbar spine (T1-T12). Determining the source of a patient's pain in the upper thoracic region can be difficult. In addition to the previously-mentioned sources of pain, pain can be due to costovertebral and/or costotransverse joint hypomobility, and active trigger points.10 Although there are many sources of thoracic pain, it has been found that it is primarily caused by mechanical disorders. Mechanical pain is defined as any type of back pain caused by placing abnormal stress and strain on muscles of the vertebral column. Typically, mechanical pain results from bad habits such as poor posture, poorly-designed seating, and incorrect bending and lifting motions.11 With the increase of inactivity due to the introduction of technology such as the computer, the general population, including the young and middle-aged, have had an increase in thoracic spine pain.11 The majority of individuals are spending countless hours in front of a computer screen without proper posture due to tight musculature, improper set up of a work station, and a lack of muscular endurance to maintain proper posture. The result of poor posture and static positioning has caused an increase in mechanical pain. Approximately 13% of the general population has had thoracic spine pain in their lifetime, with a higher prevalence 3 in child and adolescent populations (14-38%), and particularly for females (9-72%).12 With such a wide range of prevalence in the population, it has been concluded that there are different risk factors for each age population. In children and adolescents, thoracic spine pain is associated with the female gender, postural changes due to backpack use, backpack weight, other musculoskeletal symptoms, participation in specific sports, chair height at school, and difficulty with homework. Poorer mental health and age transition from early to late adolescence were significant risk factors for thoracic spine pain (TSP).12 In adults, TSP is associated with concurrent musculoskeletal symptoms and difficulty in performing activities of daily living. The duration of thoracic spine pain from the acute stage to recovery is usually
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