VERY cool case presentation

Posted: March 9, 2012 in Uncategorized

This is my first case presentation on my blog…so exciting. I had a VERY interesting (and awesome) case at my clinic this week that I had to share with whoever wants to listen. I always feel hesitant to write about clinical cases  because I realize there are many ways to skin a cat and I’m sure another therapist will come along and tear apart my diagnosis and subsequent treatment. This case however, the results were unlike any I have experienced yet as a physiotherapist.

A 43-year-old woman presented to clinic 3 days ago suffering from a 3 year off and on again history of “heaviness in the ears”. This was accompanied by bouts of dizziness and a slight ringing in the ears as well…she has become VERY annoyed with this and stated it was messing up her life. At first my red light caution flag came up, so I did a very thorough history and exam. Her reported mechanism of injury was doing a dive in her pool, twisting her neck. I immediately thought “uh oh, vertebral artery issues”. So I asked her about the 5 D’s and 2 N’s which were all negative. Her BP was 128/85 (not bad). Her HR was 73 BMP. Even though the sensitivity and specificity of the vertebral artery stress test sucks, I did it anyways (why not, right?). It was negative as well. She had no recent trauma to speak of.

Does this look fun?? NO!

I then thought about BPPV (vertigo). I did the dix-hallpike test bilaterally which revealed no nystagmus or dizziness…does anyone like doing this test? I don’t like throwing my clients down to the bed repeatedly and I’m sure they don’t love it either…But I digress

I remembered reading an article  that talked about upper cervical spine restrictions leading to altered proprioceptive input to the brain leading to sensations of dizziness and ringing in the ears. So, I checked the craniovertebral area and BAM…barley any movement was noted at C1-C2 bilaterally into right and left rotation on accessory glide tests…yeah, yeah I know…PIVM testing is garbage and unreliable…but hey, this is what I felt…it just wasn’t moving. Since this was the largest clinical finding I found I made a decision to treat it. I started with mobilizations…I did that for about 3-4 minutes and it really didn’t change her accessory glide testing. Her upper cervical flexion test was also at about 30 degrees bilaterally (should be roughly 45 on both sides) . I asked my patient if she was alright with me manipulating her neck to free up the restrictions. I told her the risks and benefits and made her aware that if she was at all uncomfortable we could do other things. She was happy to let me do the manip. I put her in the pre-manip hold—zero pain noted by the client. I then did a HVLA thrust at C1-C2 on both sides. Cavitation was noted on first attempt…always nice when that happens.

After the manip, I had her stay on the table for a few minutes. She felt fine and proceeded to sit up. She sat on the side of my treatment table and started to smile…then laugh…and then cry. She stated “I have had this issue for ages and it’s gone…all gone”. It was a great feeling to have helped her with her issue. I saw her again the very next day for follow up. She said she was 90% better and very happy. I did myofascial work on her suboccipitals, scalenes, levator scapula, splenius capitus, and upper traps. I sent her home with chin tucks and scapula retractions as a home program. She called me today at the clinic saying she woke up this morning with zero symptoms….SWEET!

Suboccipital release Doesn't it just look great...

Ok, here is the moral of the story: I went on a hunch…did I know with 100% certainty that her issues was neck related…I’d be lying if I said yes. I went with my best guess and it paid off for me in this instance. Taking manual therapy courses and being an avid reader of the literature has afforded me the ability to know the risk-benefit ratio for the techniques I employ. I know the risk of neck manips (it’s minimal) and I cleared her for everything beforehand. I recalled reading a study (now I remember where I found it)… here’s the link  that showed a very high success rate with manipulative therapy to the neck with the symptoms my client presented with. I wouldn’t start maniping everyone with ear problems, but if you can differently diagnose and rule out issues, you’re well on your way to figuring out why your clients have pain. I don’t use neck manipulation very much as I think for many issues there are better treatments to give (muligan mobs, massage, traction, thoracic manip etc). But for the amount of restriction I felt, I just felt it needed to be done…and I’m happy it proved successful!

Hope this little case presentation was interesting. If anyone has any other ideas about treatment or differentials for this presentation I am very happy to learn!

Thanks for reading.

  1. JD Garcia says:

    Nice post. I was wondering if she would respond to UPA’s and CPA’s on the UCS too. And did you try to look at her DNF? This is amazing what a Grade V can do in terms of patient symptoms resolution.


    • jessephysio says:

      Thanks for reading JD. This might sound like a dumb questions but what does UPA, CPA and UCS stand for? I think DNF means deep neck flexors? I did check them and they were bad. I will address that first thing when I see her next week. The chin tucks will aid in the DNF recruitment though. I will probably have her do it in quadruped for some gravity resisted stuff…see how that goes.

    • Jan says:

      Nice post, I have recently graduated and I would like to carry on with my physio education in neuromusculoskeletal field, even though I am wondering about the manips: if a manipulation is performed by someone-a student who is learning it, could it cause a damage to the mock patient-that isusually an other student? i am quite frightened about the idea that someone who is not trained and is actually learning how to do it would perform a manipulation on my neck, spine…Could you suggest some articles or book to read about it?


  2. Vincent says:

    Thanks for a great post! There are many times where I feel that I can make the most impact with HVLA esp in the c-spine, but usually resort to MET/MWMs and Tspine or CTjxn HVLAs. It’s hard for me to get over possible adverse response (although extremely small).
    It’s funny, some would argue that basic Cspine rom exercise or even graded mobs are just as, if not more taxing on the VA.
    Kudos on your immediate success!

  3. Stacey says:

    I’m glad your hunch went well. It’s nice to see someone go with their gut, and try something new based on their client. It was a risk but it lead to a good outcome. Thumbs Up!

  4. Great Job Jesse! Even though I teach promote thrust, I actually haven’t done a C1-2 rotatory thrust since I was taught years ago. Good job on the screening (I just wouldn’t have bothered with the VA test), I’m assuming you meant for upper cervical flexion test being 30 and not 45 you meant with rotation, correct? I will be linking back this weekend on my blog

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