What is the working hypothesis for each case? What two questions and two tests would you use to rule in your hypothesis?
1. Pt is a 40 year old male with left sided upper cervical pain, pain with rotation to the left and extension.
2. Patient is 34 year old female with restricted range of motion, moderate to severe pain. Pins and needles into the left middle finger.
3. 52 year old male with moderate pain in the right cervical spine, dull pain radiating into the left upper arm, occasional on and off tingling into the right thumb.
4. 60 year old male, report funny feeling of disequilibrium, neck pain, notes decrease cervical motion with end range pain.
5. 58 year old female post MVA 2 weeks with moderate pain irritation note with daily activity, ROM is painful at 75% range all planes. with pain no radicular sx.
6. 58 year old male with pain in the arm down to the medial right elbow after paining ceilings. Had this pain 3 years prior.
7. 45 yo female presenting with complaints of left cervical pain and tightness with complaints of numbness and tinging present in the thumb hand (thumb and thenar) began with insidious onset.
Great discussion on differentiation in disc pathologies and presentations. Please view this week along with the condition script for acute disc herniation.
By Jim Meadows
The condition scripts highlight the key subjective and objective information used to create your initial hypothesis. These are the typical presentations for each condition and work well with non complex cases.
2-3 focused questions and the 2 tests are used to rule in the diagnosis. Ideally one test that is sensitive and one test that is specific would be the best option but the validity of many special tests are questionable. In this part of the process general questions may confound the reasoning process so keep the questions focused on the condition scripts. Followup questions and examination will be focused and serve as bias correction to further rule out competing differentials and to identify contributing etiologies.
When performing the biomechanical assessment with a subluxed joint or precapsular restriction we will have a restricted passive physiological intervertebral motion(PPIVM). We will then proceed to check the end feel with the passive arthrokinematic intervertebral motion(PPAVIM) to determine if the end feel is pericapsular restriction(hard capsular) or a subluxed pathomechanical end feel.
In the presence of a normal, muscle hypertonicity or hypermobile end feel the PAIVM is not required since we already know there is not a restricted end feel. The links below are to the biomechanical assessment and manipulation for the jammed(subluxed end feel).
Script focused deduction uses minimal information to develop and test a hypothesis. A few key pieces of information are gathered to develop your first hypothesis or the ” H1″. From the H1, 2-3 questions and 2 tests are then used to support or reject the hypothesis. This is very useful for the developing therapist to establish a provisional hypothesis.
Experts use pattern recognition where 4-5 common differential presentations are compared to the patient presentation. These are the common conditions seen in clinic and they focus the subjective and objective examination on ruling in or out this condition. Script focused deduction allows the therapist to start developing pattern recognition. Over the next 8 modules we will be working on developing clinical reasoning skills starting with script focused deduction.
The next section is adapted from Jim Meadows work on script focused deduction. He uses elbow pain as an example case. In the next post we will look at the lumbar essential illness scripts.
In short more time can be spent on the more complex aspects of the problem (level of inflammation, etiology and contributing remote pathologies etc.) when less time has to be spent on the differential diagnosis
The uncomplicated diagnosis should be easily available to non- experts and not a struggle
It mimics what experts do with pattern recognition, that is ask a few supporting questions and do a few tests, without the experience of expertise being required
But by completing all aspects of the examination after the diagnosis has been made it reduces bias and error
For more information here is a link to moodle for Jim Meadows manual on Script focused deduction. If not in a current course email me and I can forward you the text.
TBWF Episode 4 – Listen to Fred Stoot and his colleagues discuss PT related topics.
TBWF Episode 2 – Listen to Fred Stoot and his colleagues discuss PT related topics.
TBWF Episode 1 – Listen to Fred Stoot and his colleagues discuss PT related topics.
Coming soon…podcasts from IMPACT featuring discussions about manual therapy with emphasis on critical thinking.
Fit Demonstrations of techniques used in the the article: Use of Thoracic Spine Thrust Manipulation for Neck Pain and Headache in a Patient Following Multiple-Level Anterior Cervical Discectomy and Fusion: A Case Report
These techniques are part of the IMPACT curriculum. Additional more segmental specific techniques are taught in all IMPACT courses.
Posted by IMPACT Fellows in Training Shannon VanAntwerp PT and Matt Johnson PT.
The Use of Upper Thoracic Manipulation in a Patient With Headache. James A. Viti MSc, PT, OCS, Stanley V. Paris, PhD, PT. The Journal of Manual & Manipulative Therapy Vol. 8 No. 1 (2000), 25 – 28.
Assessment: PIVM and PAIVM in flexion and extension.
Treatment: Upper thoracic manipulation is effective in relieving cervicogenic headache symptoms. In addition to upper cervical mobilizations and soft tissue mobilization, upper thoracic helped to reduce headache symptoms. Decreasing upper thoracic hypomobility may improve forward head posture and CV extension. Thrust techniques to the segments where the semispinalis capitus attach may cause reflex inhibition to that muscle and decrease associated pain referral/ headache symptoms.