Differential diagnosis and management of a patient with peripheral vestibular and central nervous system disorders: a case study

Background

Clinical examination and management of patients with meningiomas is primarily dependent upon appropriate diagnosis of tumor type and surgical intervention. Physical therapists should be able to identify patients presenting with signs and symptoms suggestive of potential central nervous system (CNS) disorders and refer the patient appropriately.

Patient characteristics

In this case report, a 52-year-old female was referred to physical therapy after 18 months of unresolved dizziness.

Examination

Oculomotor examination revealed evidence of peripheral vestibular and potential CNS disorders. The physical therapist referred the patient to a physician who ordered magnetic resonance imaging (MRI).

Intervention

The patient received five physical therapy sessions while waiting for the MRI which revealed a meningioma. The meningioma was surgically removed and the patient was subsequently relieved of all symptoms.

Outcomes

Despite the presence of the meningioma, the patient reported improved stability during work-related activities and decreased dizziness as a result of physical therapy intervention pre-operatively.

Discussion

This case report emphasizes the importance of a physical therapists ability to perform and interpret an oculomotor examination in a patient presenting with signs consistent with peripheral vestibular and CNS disorders. It also demonstrates the role of physical therapy in collaboration with physicians in order to provide appropriate patient care management.     

The status of temporomandibular and cervical spine education in credentialed orthopedic manual physical therapy fellowship programs: a comparison of didactic and clinical education exposure

Objective:

The purpose of this investigation was to establish a baseline of physical therapist education on temporomandibular disorders (TMD)-related topics during credentialed orthopedic manual physical therapy fellowship training and compare it to cervical spine disorders education.

Method:

An online survey was distributed electronically to each fellowship program credentialed by the American Physical Therapy Association (APTA) and recognized by the Academy of Orthopedic Manual Physical Therapists (AAOMPT). Data were analyzed to compare overall exposure to TMD educational content, including a direct comparison of TMD and cervical spine disorders education.

Results:

The response rate was 79%. Thirteen programs (87%) reported providing both didactic and clinical training on both TMD and cervical spine disorders. Didactic education for cervical spine disorders ranged from 16–20 hours to over 25 hours, whereas TMD hours ranged from 0 to 6–10 hours. Clinical education for cervical spine disorders ranged from 11–15 hours to over 25 hours, whereas TMD hours ranged from 0 to 6–10 hours. The number of hours of exposure during didactic training and the number of patients exposed to during clinical training were significantly different when comparing TMD to cervical spine disorders exposure (P<0.0001).

Discussion:

The data indicate a lack of uniformity between credentialed fellowship programs in orthopedic manual physical therapy with respect to the extent to which programs expose trainees to evaluation and management of TMD. There is consistency in that all programs provided more training on cervical spine disorders than TMD. Despite a high level of clinical specialization, fellows-in-training receive minimal TMD education.     

Lymphedema self-care in patients with head and neck cancer: a qualitative study

Purpose

Lymphedema is a frequent side effect from head and neck cancer and/or its treatment. As a chronic and progressive condition, it requires an individual’s long-term involvement in self-care for management of lymphedema. This study aimed to report head and neck cancer patients’ perceived lymphedema education, self-care practices, and suggestions related to self-care of head and neck lymphedema.

Methods

Twenty head and neck cancer patients who completed lymphedema therapy participated in semi-structured face-to-face interviews. Interviews were audio-recorded and transcribed. Content analysis was used to analyze the interview data.

Results

All participants reported that they were educated about self-care activities for lymphedema management by their lymphedema therapists. Although most participants (n = 16, 80 %) expressed positive comments about lymphedema self-care education, some participants (n = 7, 35 %) described issues related to lymphedema self-care education. A majority of the participants (n = 17, 85 %) reported that they were conducting some lymphedema self-care activities; nonetheless, more than half of the participants (n = 11, 55 %) delineated barriers for diminished lymphedema self-care activities over time. Participants further indicated suggestions for improving and ensuring consistency of lymphedema self-care.

Conclusions

Opportunities exist to improve lymphedema self-care in head and neck cancer patients. Healthcare professionals should focus on delivering high quality and targeted information about self-care for management of head and neck lymphedema. Interventional research is warranted to address gaps in long-term self-care of head and neck lymphedema.

     

Differential diagnosis and early management of rapidly progressing hip pain in a 59-year-old male

Objective and importance

Rapidly progressing degeneration of the hip joint is an uncommon condition presenting to physical therapy. Differential diagnosis can often be difficult, as clinical and radiographic findings do not always coincide leaving clinicians with difficult decision making regarding course of treatment. The purpose of this case report was to describe the differential diagnosis and early management of a patient with rapidly progressing hip pain.

Clinical presentation

A 59-year-old male with a complicated medical history was referred with a diagnosis of severe bilateral hip osteoarthritis. Clinical presentation of insidious onset, severe bilateral groin and anterior thigh pain with rapid progression of functional decline lead to the differential diagnosis of bilateral avascular necrosis.

Intervention

The patient received seven manual physical therapy sessions over the course of one month.

Conclusion

During this time, the patient’s Lower Extremity Functional Scale score worsened from 33 to 21. The persistence of the patient’s painful symptoms and continued functional decline helped determine cessation of manual therapy and referral back to his GP for further diagnostic testing and eventual correct diagnosis. This case highlights the importance of monitoring patient prognosis using outcome measures leading to a change in patient management strategies.     

Body posture changes in women with migraine with or without temporomandibular disorders

Background

Migraine and temporomandibular disorders (TMDs) are reported to be associated. However, there are no reports on the association among migraines, TMDs and changes in body posture.

Objectives

To assess changes in body posture in women suffering migraines with or without TMD compared with a control group.

Method

Sixty-six women with a mean age of 18 to 45 years participated in this study. The groups were composed of 22 volunteers with migraine and TMD (MTMD), 22 volunteers with migraines without TMD (MG) and 22 women in the control group (CG). Static posture was assessed by photogrammetry, and 19 angles were measured.

Results

Postural asymmetry was observed in the face for 4 angles measured on the frontal plane in the MG group and for 4 angles of the trunk in the MG and MTMD groups with respect to CG. However, for comparisons between MTMD and CG, clinical relevance was identified for two angles of the sagittal plane (Cervical and Lumbar Lordosis, Effect Size - ES - moderate: 0.53 and 0.60). For comparisons between the MG and CG, the clinical relevance/potential was verified for three angles with moderate ES (ES>0.42). The clinical relevance when comparing MTMD and CG was identified for four angles of facial symmetry head inclination (ES>0.54) and for two angles between MG and CG (ES>0.48).

Conclusion

The results demonstrated the presence of postural changes compared with a control group in women with migraines with or without TMD, and there were similar clinically relevant postural changes among the patients with migraines with and without TMD.     

Manual physical therapy and perturbation exercises in knee osteoarthritis

Objectives:

Knee osteoarthritis (OA) causes disability among the elderly and is often associated with impaired balance and proprioception. Perturbation exercises may help improve these impairments. Although manual physical therapy is generally a well-tolerated treatment for knee OA, perturbation exercises have not been evaluated when used with a manual physical therapy approach. The purpose of this study was to observe tolerance to perturbation exercises and the effect of a manual physical therapy approach with perturbation exercises on patients with knee OA.

Methods:

This was a prospective observational cohort study of 15 patients with knee OA. The Western Ontario and McMaster Universities Arthritis Index (WOMAC), global rating of change (GROC), and 72-hour post-treatment tolerance were primary outcome measures. Patients received perturbation balance exercises along with a manual physical therapy approach, twice weekly for 4 weeks. Follow-up evaluation was done at 1, 3, and 6 months after beginning the program.

Results:

Mean total WOMAC score significantly improved (P = 0.001) after the 4-week program (total WOMAC: initial, 105; 4 weeks, 56; 3 months, 54; 6 months, 57). Mean improvements were similar to previously published trials of manual physical therapy without perturbation exercises. The GROC score showed a minimal clinically important difference (MCID)≥+3 in 13 patients (87%) at 4 weeks, 12 patients (80%) at 3 months, and 9 patients (60%) at 6 months. No patients reported exacerbation of symptoms within 72 hours following each treatment session.

Discussion:

A manual physical therapy approach that also included perturbation exercises was well tolerated and resulted in improved outcome scores in patients with knee OA.     

EFFECTIVENESS OF PHYSICAL THERAPIST ADMINISTERED SPINAL MANIPULATION FOR THE TREATMENT OF LOW BACK PAIN: A SYSTEMATIC REVIEW OF THE LITERATURE

Background Context:

Low back pain (LBP) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses. A common intervention for LBP is spinal manipulation, a technique that is not specific to one scope of practice or profession.

Purpose:

The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain.

Methods:

A search of the current literature was conducted using PubMed, CINAHL, SPORTDiscus, Pro Quest Nursing and Allied Health Source, Scopus, and Cochrane Controlled Trials Register. Studies were included if each involved: 1) individuals with LBP; 2) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations; 3) measurable clinical outcomes or efficiency of treatment measures, and 4) randomized control trials. The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Database (PEDro).

Results:

Six randomized control trials met the inclusion criteria of this systematic review. The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes. Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported statistically significantly less medication use, health care utilization, and lost work time.

Conclusion:

Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain.     

Intra-oral myofascial therapy for chronic myogenous temporomandibular disorders: a randomized, controlled pilot study

Objectives

Studies investigating the efficacy of intra-oral myofascial therapies (IMT) for chronic temporomandibular disorder (TMD) are rare. The objective of this randomized, controlled pilot study was to compare the effects of IMT and the addition of self-care and education over 6 months on four common TMD outcome measures: inter-incisal opening range, jaw pain at rest, jaw pain upon opening, and jaw pain upon clenching.

Participants

Thirty myogenous TMD participants between the ages of 18 and 50 years, experiencing chronic jaw pain of longer than 3-month duration, were recruited for the present study.

Intervention

Included patients were randomized into one of three groups: (1) IMT consisting of two treatment interventions per week for 5 weeks; (2) IMT plus ‘self-care’ involving education and exercises; and (3) wait list control.

Main outcome measures

Range of motion findings were measured in millimetres by vernier callipers and pain scores were quantified using an 11-point self-reported graded chronic pain scale. Measurements were taken at baseline, 6 weeks post-treatment, and 6 months post-treatment.

Results

The results showed statistically significant differences in resting, opening, and clenching pain and opening range scores (P<0.05) in both treatment groups compared to control at 6 months. No significant differences were observed between the two treatment groups during the course of the trial.

Conclusions

This study suggests that IMT alone or with the addition of self-care may be of some benefit in the management of chronic TMD over the short-medium term. A larger scale study over a longer term (1–2 years) may be of further value.     

Short- and long-term clinical outcomes following a standardized protocol of orthopedic manual physical therapy and exercise in individuals with osteoarthritis of the hip: a case series

Objectives:

Describe short- and long-term outcomes observed in individuals with hip osteoarthritis (OA) treated with a pre-selected, standardized set of best-evidence manual therapy and therapeutic exercise interventions.

Methods:

Fifteen consecutive subjects (9 males, 6 females; mean age: 52±7.5 years) with unilateral hip OA received an identical protocol of manual therapy and therapeutic exercise interventions. Subjects attended 10 treatment sessions over an 8-week period for manual therapy interventions and performed the therapeutic exercise as a home program.

Results:

Baseline to 8-week follow-up outcomes were as follows: Harris Hip Scale (HHS) scores improved from 60.3(±10.4) to 80.7(±10.5), Numerical Pain Rating Scale (NPRS) scores improved from 4.3(±1.9) to 2.0(±1.9), hip flexion range of motion (ROM) improved from 99 degrees (±10.6) to 127 degrees (±6.3) and hip internal rotation ROM improved from 19 degrees (±9.1) to 31 degrees (±11.5). Improvements in HHS, NPRS, and hip ROM measures reached statistical significance (P<0.05) at 8-weeks and remained significant at the 29-week follow-up. Mean changes in NPRS and HHS scores exceeded the minimal clinically important difference (MCID) at 8-weeks and for the HHS scores alone at 29 weeks. The 8 and 29 week mean Global Rating of Change scores were 5.1(±1.4) and 2.1(±4.2), respectively. Improved outcomes observed following a pre-selected, standardized treatment protocol were similar to those observed in previous studies involving impairment-based manual therapy and therapeutic exercise for hip OA. Future studies might directly compare the two approaches.

Discussion:

     

A Preliminary Report on the Efficacy of a Dynamic Jaw Opening Device (Dynasplint Trismus System) as Part of the Multimodal Treatment of Trismus in Patients With Head and Neck Cancer

Stubblefield MD, Manfield L, Riedel ER. A preliminary report on the efficacy of a dynamic jaw opening device (Dynasplint Trismus System) as part of the multimodal treatment of trismus in patients with head and neck cancer.

Objective

To examine the effectiveness of a dynamic jaw opening device as part of a multimodal treatment strategy for trismus in patients with head and neck cancer.

Design

Retrospective cohort study.

Setting

Tertiary care cancer center.

Participants

Patients with head and neck cancer and trismus (N=20).

Intervention

All patients underwent assessment by a board-certified physiatrist and were referred to physical therapy for delivery of the DTS and instructed to progress use of the DTS to 30 minutes 3 times a day. Additional modalities for the treatment of trismus including pain medications and botulinum toxin injections were prescribed as clinically indicated.

Main Outcome Measures

Change in maximal interincisal distance (MID) as documented in the medical record.

Results

The use of the DTS as part of multimodal therapy including physical therapy, pain medications, and botulinum toxin injections as deemed clinically appropriate resulted in an overall improvement of the MID from 16.5mm to 23.5mm (P<.001). Patients who could comply with the treatment recommendations for DTS treatment did better than those who could not, with an improvement of the MID from 16mm to 27mm (P<.001) versus 17mm to 22mm (P=.88).

Conclusions

The DTS is a safe and effective component of a multimodal strategy for improving trismus associated with head and neck cancer and its treatment. Further investigation is needed to determine the relative efficacy of the treatment modalities available for trismus including physical therapy and other jaw stretching devices.     

Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series

Study design

A case series of consecutive patients with chronic low back pain.

Background and purpose

In patients with chronic low back pain (CLBP), the importance of impairments at the hip joints is unclear. However, it has been postulated that impairments at the hip joints may contribute to CLBP. The purpose of this case series was to investigate the short-term outcomes in patients with CLBP managed with impairment-based manual therapy and exercise directed at the hip joints.

Methods

Eight consecutive patients (mean age: 43·9 years) with a primary report of CLBP (>6 months) without radiculopathy were treated with a standardized approach of manual physical therapy and exercise directed at bilateral hip impairments for a total of three sessions over approximately 1 week. At initial examination, all patients completed a numeric rating pain scale (NPRS), Oswestry disability index (ODI), fear-avoidance beliefs questionnaire (FABQ), and patient-specific functional scale (PSFS). At the second and third treatment sessions, each patient completed all outcome measures as well as the Global Rating of Change (GROC).

Results

Five of the eight (62·5%) patients reported ‘moderately better’ or higher (>+4) on the GROC at the third session, indicating a moderate improvement in self-reported symptoms. These five individuals also experienced a 24·4% reduction in ODI scores.

Discussion

This case series suggests that an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a plausible explanation regarding the clinical outcomes of this study. A larger, well-controlled trial is needed to determine the potential effectiveness of this approach with patients with CLBP.     

Static body postural misalignment in individuals with temporomandibular disorders: a systematic review

BACKGROUND:

The association between body postural changes and temporomandibular disorders (TMD) has been widely discussed in the literature, however, there is little evidence to support this association.

OBJECTIVES:

The aim of the present study was to conduct a systematic review to assess the evidence concerning the association between static body postural misalignment and TMD.

METHOD:

A search was conducted in the PubMed/Medline, Embase, Lilacs, Scielo, Cochrane, and Scopus databases including studies published in English between 1950 and March 2012. Cross-sectional, cohort, case control, and survey studies that assessed body posture in TMD patients were selected. Two reviewers performed each step independently. A methodological checklist was used to evaluate the quality of the selected articles.

RESULTS:

Twenty studies were analyzed for their methodological quality. Only one study was classified as a moderate quality study and two were classified as strong quality studies. Among all studies considered, only 12 included craniocervical postural assessment, 2 included assessment of craniocervical and shoulder postures,, and 6 included global assessment of body posture.

CONCLUSION:

There is strong evidence of craniocervical postural changes in myogenous TMD, moderate evidence of cervical postural misalignment in arthrogenous TMD, and no evidence of absence of craniocervical postural misalignment in mixed TMD patients or of global body postural misalignment in patients with TMD. It is important to note the poor methodological quality of the studies, particularly those regarding global body postural misalignment in TMD patients.     

The effect of manual therapy with augmentative exercises for neck pain: a randomised clinical trial

Objectives

To compare the effect of manual therapy (MT) and an augmentative exercise programme (AEP) versus MT and general neck range of motion (ROM) on functional outcomes for patients with neck pain. A secondary objective was to examine changes in self-report measures and quantitative sensory testing (QST) following MT and AEP.

Methods

This was a randomised clinical trial. Seventy-two patients with neck pain were recruited. All patients received a single session of MT. Patients were randomly assigned to MT+AEP or MT+ROM. Clinical self-report outcome measures for disability and pain, and QST measures (pain and vibration thresholds) were collected at baseline, post MT treatment, at ∼48 hours, and at ∼96 hours. Repeated measures ANOVA and MANOVA were used to analyse within and between-group effects for clinical and QST measures.

Results

There were no between-group differences for disability, pain and QST measures. There was, however, a significant difference between groups for Global Rating of Change (GRoC) scores (P = 0.037). Patients in both groups showed improvements in pain, disability and trapezius pressure-pain threshold (PPT) (all P < 0.001).

Discussion

Augmentative exercise programme does not significantly improve disability, pain or QST measures in patients with chronic neck pain although it may enhance their GRoC scores. Over a 96-hour period, patients benefitted from MT plus exercise whether the exercise was general or specific.