Complex case study

This is a great article for the “n” of one crowd. Not every article has to be a randomized control trial and sometimes we can learn much more from a case report than from a systematic review. This is one case report that taught me to be a little more exhaustive than I typically am when treating a patient. When a patient presents to the clinic with facial pain, the “jump to conclusion” idea is that the patient has larger issues that need to be addressed, as this is a sign of a cranial nerve (think direct to the brain nerve) dysfunction. I forgot some details of the nervous system, or a better way of saying it is that I didn’t have a complete understanding of this coming out of PT school that this review is more of a clinical application of the anatomy in order for it to make more sense. My ego is not too big to say that I am still learning daily. This article makes me a better therapist tomorrow than I was yesterday. Thank you J. Lincoln.


Big picture, the patient improved. We can’t draw cause and effect conclusions from a single case, but we can take the information provided and use it on a later patient in which stronger research-based interventions have failed the patient.


  1. “female…with symptoms of unilateral right sided head,face,ear, neck, shoulder and arm pain, as well as subjective sensation of swelling in the right side of the face and anterior triangle of the neck”


Yeah…we don’t particularly like seeing these types of patients. Especially not on a Friday after noon at 4PM. These symptoms are going to be difficult to try to figure out. Many therapists (myself included when I was a young buck) would just write this patient off as one of two things:

  1. psychosomatic: look it up. You will find that the psycho plays a role in the pain presentation. By psycho, I don’t always mean the patient, but the patient’s perception of the pain.
  2. secondary gain: This patient was either in a car accident looking for litigation, is trying to score some time off of work, or is trying to get money without working for it.


Needless to say, I don’t tend to lump patients into these categories as quickly as I did in the past ( I still do, as this is also a part of classifying patients), but I will at least take a crack at helping the patient before jumping to one of the above conclusions. On a side note: if you are faking/exaggerating or seeking some sort of financial gain, please don’t seek me out. I take pride in thoroughly assessing you and if I find inconsistencies in your presentation, it will not look good for your case.


  1. “referred for neck pain…complained of a constant ache in the right shoulder and neck extending down the entire anterior aspect of the right arm…intermittent pain in the right side of the face, ear and head as well as a constant sensation of swelling in the right side of the face and anterior triangle of the neck…waking at night with right arm pain…intermittent pins and needles in the right fingertips…aggravating activites included reaching or lifting with the right arm, ironing or wringing out clothes. Cold weather or having influenza generally made all symptoms worse…blowing her nose or sneezing specifically increased her facial pain.”


Get ready to swim because we are going into the deep end.


  1. Neck pain radiating down the arm. This is a very common symptom and can be coming from any structure that radiates symptoms down the arm (such as disc, nerve, facet) or from the brain’s heightened state of response to threat. This is a common symptom and I always think that there is a mechanical problem and force the patient’s symptoms to make me change my mind.

When assessing all patients, it is like one big chess game. Every movement and question that I ask of you provides me with your first move. I always let the patient start, except for very rare cases. Once the patient starts with their history or the first movements, the chess game begins. Every move the patient makes leads me to my next move. It is really like one complex dance. I will follow your lead and then take the lead when your body has given me my checkmate. Once I know how to win, I completely take the lead.

  1. intermittent pain in the face, ear and head leads most therapists to start thinking cranial nerves. These nerves are interesting because they don’t go through the spine. Think of it this way, why should the nerves go down into the spine only to come back up into the face. There is a much shorter distance from the brain to the face. When the face starts experiencing symptoms, we think brain first (and always keep this in the back of our minds if there is no change in the patient’s symptoms with movement, as nerves from the brain to the face won’t change much with neck movements). Secondly, the upper portion of the neck can refer into the head and face. Neck movement’s can affect these symptoms. This is why it is important to have a thorough evaluation.
  2. waking up at night with arm pain can be considered a red flag (think red light as our stop sign) and the therapist may start thinking of things such as cancer, but again the mechanical evaluation will help to start weeding out the white board (House MD reference).
  3. cold weather or influenza: This could also signal a systemic issue having a role in the patient’s systems.


Overall, the white board just got very confusing.


  1. “insidious onset of pain over a 12 month period, which had gradually worsened…no past history of shoulder or cervical spine injury…medical history included …diabetes, angina (chest pain), dizziness associated with postural changes and blurred vision bilaterally (both eyes)”


Big picture, this patient has a lot of stuff going on! I would call the doctor to ensure that he/she is aware of the atypical symptoms of blurred vision (possibly brain issue), dizziness (could be brain issue, neck issue, eye issue or ear issue) and chest pain (could be neck issue or heart issue). The fact that the patient is worsening over time is also a red flag that would also need to be alerted to the physician.


Many would think that the physician should already know all of this, but as a former teacher “Master John Luby” once said: “Never should on yourself” (say it fast and it will make sense). Most all of us have been to the doctor. I hear stories frequently from patients that they only see the physician for 5-10 minutes (if they ever see the physician at all). The therapist gets anywhere from 30 minutes to 1 hour with the patient and more information can be garnered in this time period (if the therapist cares enough to ask).


  1. “protracted cervical spine with forward head”


This is unfortunately more and more common. I can count on one finger how many patients enter the clinic with good posture. If your posture is crappy, then your movement will also be crappy. If you can’t stand still with good form, what makes you think that you can walk, run, jump, squat, or lift with good form.


  1. “an increase in the shoulder and neck pain at the end of range for left rotation and left lateral flexion”


This would indicate that opening up the facet joints would provoke symptoms. The spine has 3 holes in it…don’t worry, they are supposed to be there. When you move in a direction you can only do 1 of 2 thing to the hole: open or close. When you move to the left (either side bend like holding a phone to your ear or rotating in such a way to look over the left shoulder) you close down the left holes of the neck and open up the right holes of the neck. Opening up the right hole provokes symptoms.


  1. “Cervical spine extension produced central thoracic pain. Flexion, right rotation and right lateral flexion were asymptomatic”


looking up was no good, but looking right and leaning right were great. Looking down was okay. This creates a complicating factor because when you look down, you open the right hole and when you look up, you close the right hole. This patient will not be as simple as which holes are opening and closing.


  1. “arm,shoulder and neck pain was increased with flexion from 90 degrees through end range, abduction initially at 100 degrees through end range, and at the end of range with the hand behind the back movement”


White board: shoulder problem, neck problem, nerve problem.


Raising the arm can place tension on a nerve (they don’t like tension). Placing the arm behind the back doesn’t place tension on the same nerve, so this would start to rule out nerve tension as the major source of problems.


Neck problems can mimick all of the above symptoms, so not ruled out yet.


Shoulder problems can mimic the shoulder pain with the movement, but doesn’t typically cause neck pain with the movements.


Based on the pain presentation, we should probably start by looking at the neck.

  1. “Position assessment of the axis vertebra via palpation revealed the right transverse process to be prominent posteriorly as well as tender. This possibly suggested some rotation of this vertebra”


I understand what the author is saying, but I am so far removed from assessing each individual segment that I find it hard to believe that this is still a major component of performing a cervical evaluation.


  1. “patient was given a modified…neural mobilization exercise for home”


This doesn’t make sense to me when the author initially thought that there was a neck problem based on palpation. If I thought that you had a lug nut loose, I wouldn’t recommend putting air in the tire as a fix.


  1. “reported an initial increase in symptoms for 2 days and then large decrease for subsequent 4 days…active cervical spine movements reproduced right shoulder and neck pain at the end range or right rotation and right lateral flexion…it was decided to test for upper cervical spine stability…symptoms had virtually disappeared to a minor sensation…directly after treatment (headache snag).


Again, there are some topics here that seem like illogical jumps. The symptoms in the neck shifted sided from left to right. This is common, so I can understand that the symptoms shifted sides, but I can’t understand how the therapist made the jump to test for cervical instability after already having done all of the cervical movements. When a spine is unstable, it is like balancing a golf ball on a golf tee. If everything is aligned, the golf ball will stay on the tee, but if there is a slight change in alignment, off the tee it falls. Guess what your head resembles?! If there is a suspicion of cervical instability, this is a major clinical sign that needs to be assessed.


  1. “Infections in the tonsils, middle ear, teeth and nose may drain into the cervical spine region and the subsequent inflammation may lead to loosening of the transverse ligament attachments”


First, I didn’t know this. Second, this is a guess at best to state that this is the reason for the “loosening” of the ligaments of the spine.


  1. “It is therefore possible that this patient’s increased mobility was due to chronic loosening of the transverse ligament over time.”


This is a stretch and I would say long shot. First, we don’t know how mobile or hypermobile this patient was prior to the incident. The “increased mobility” may be the patient’s norm. We all know some people that can touch the floor and others that can’t even touch their knees. This may be the person’s norm.


Also, if the infections are causing the ligament loosening, then the exercises will not have a long-term effect on someone that continues to experience infections. If this is the case, then the best way to treat the facial symptoms is to treat the infection and wait to see if the ligament tightens up and the symptoms disappear.


  1. “This patient presented with pain at rest, suggesting the spine’s inability to maintain a sufficient neutral zone to prevent abnormal stresses on upper cervical spine…the development of a clinical instability situation”


If something has increased mobility from what is expected as normal, it doesn’t make sense to mobilize the segment. I don’t understand the author’s rationale for mobilizing a hypermobile segment. This may just be my ignorance though.

The patient improved over a short number of sessions.  This is obviously the goal of therapy.  If this patient’s symptoms were unchanged or worsened over the course of 6 visits, then it would be appropriate to communicate with a physician that either referred the patient or that the patient would like to see.  This is why it is important to shop around for therapists.  We have to demonstrate functional improvement.  Sometimes that function may just be reducing and eliminating pain so that you can continue to watch Game of Thrones or play the latest game on FB.

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3 thoughts on “Complex case study

  1. This would be a very uncomfortable evaluation for me. I have never had a patient with face pain so far but I am not very confident in my knowledge base for treating it. I like your commentary on #8. I am still very new to practicing but from my experience so far, most clinicians that report that they can feel an abnormality in an individual segment are either lying to the patient or lying to themselves. After palpating hundreds of backs and necks in the past year, I have only suspected that I felt an abnormality in an individual segment once, and I’m still not confident that’s really what was causing symptoms. I have spoken to therapists in the past that tell me that they can feel rotations in vertebrae or can see pelvic obliquities in every patient… I am not a fan of this method of assessment/treatment. I movement based approach is far superior in my opinion. Even if an obliquity or abnormality is able to be identified in a specific segment, wouldn’t a main focus of treatment be to determine how this happened in the first place and stop it from happening in the future instead of simply “putting it back in place?” This seems eerily similar to the outdated and invalid chiropractic model of the past and not something that I am comfortable with in my practice.

    1. I completely agree with you. I have a movement based background, so I tend to be skeptical of feeling abnormalities, but I can’t argue with a patient improving. The good thing with case studies is we get to see a different approach than the RCTs, but we can’t make the assumption that the treatments is what helped the patient when compared to time, the multimodal approach or just lifestyle changes.

      1. Or simply strong patient buy in and belief that what the clinician is doing will help them. I’m convinced that 50% or more of patient outcome is related to biopsychosocial factors.

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