Introduction
"Every patient contains a truth .... The [clinician] must adopt a conscious humility, not towards the patient, but towards the truth concealed within the patient" (Cyriax 1982, p. 45). In order to access this truth, the clinician must approach the patient in a respectful and friendly way;
they must have a logical format for collecting information, and, most importantly, they must listen actively to the patient's responses. The patient knows the details of the history, onset, symptom pattern and behaviour since onset, and aggravating and relieVing factors. Only from the patient is it possible to gain insights into various aspects of the clinical presentation, which are essential to inform issues such as the stage and nature of the disorder, the prognosis and the manage
ment. Very often the history-taking provides information that is at least as important as that gained from the physical examination, if not more so.
In mechanical diagnosis and therapy we wish to understand the effect that different movements and positions have on symptoms and use this understanding to shape an appropriate management strategy. This understanding comes through analysis of the history and physical examination.
The interview requires skills of questioning accurately and appropriately as well as listening. It is important that we make the patient as relaxed as possible, for instance by avoiding use of medical jargon that may be unfamiliar. The use of a structured, but flexible interview format so that all pertinent factors from the history and behaviour of the condition are collected will facilitate a good understanding of the patient's problem. The standardised assessment form includes the most important aspects of the history that need gathering; mostly it is unnecessary to add to this information.
It is best to gather the information using open-ended questions first, so that patients may volunteer their own answers, rather than using leading questions. Focussed questions may be used to follow up if particular aspects need more detailed information. The form should not prevent further specific questioning if this is thought to be
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CHAPTER TEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYnecessary. Thus, management decisions can be grounded in the particular patient's problem and their response to it.
Sections in this chapter are as follows:
aims of history-taking
• interview
patient demographics
•
•
age
occupationlleisure activities functional disability
• symptoms this episode previous history specific questions
• 'red flags'.
Aims of history-taking
Using the form and the appropriate questioning technique at the end of the history-taking, ideally the following will have been obtained:
• an overall impression of the clinical presentation
• the functional limitations that the condition has imposed on the patient's quality of life
• location of 'neck' pain: central/symmetrical, or unilateral!
asymmetrical; if unilateral, is the pain in the neck, scapular, shoulder and arm, or referred below the elbow
• determination if a neurological examination should be conducted the stage of the disorder - acute/sub-acute/chronic
• the status of the condition - improving/unchanging/worsening
• identification of 'red flags' or contraindications
• baseline measurements of the symptomatic (and mechanical presentations) against which improvements can be judged
• movements and positions that aggravate and relieve the problem, and the role of posture, which may help guide future manage
ment
THE HISTORY
the severity of the problem, which may gUide the vigour of the physical examination
an impression about the way the patient is responding to their condition, and how much encouragement, information, reas
surance or convincing they may need to be active participants in their own management
a hypothetical diagnosis by syndrome.
Interview
During the history-taking, seat the patient on the treatment table or a backless chair so that they reveal their true relaxed sitting posture.
Patient demographics Age
Patients are more susceptible to certain problems at different times of life. Postural syndrome is more likely to be present in the young, whilst young to old adults have derangements and dysfunctions.
Osteoporosis is generally only relevant in the elderly, espeCially post
menopausal women, although there are exceptions. With increasing age spinal degeneration is more likely to be present, the intervertebral disc becomes dehydrated and fibrosed, and osteophytes and other bony changes can occur around the zygapophyseal and uncovertebral joints and vertebral bodies (Taylor and Twomey 2002). Such changes may predispose to spinal stenosis affecting nerve roots or the spinal cord. MalignanCies are also more common in the older age group.
Completely new onset of headache or neck pain in older patients who have never experienced this before is also a possible warning symptom.
The age of the patient may also be Significant in their response to the problem. Increasing years not only raises the susceptibility to disease and injury, but also reduces the body's ability to recover from the effects of musculoskeletal disease and injury (Buckwalter et aI.1993).
A patient's age may thus be important in their prognosis.
Occupation/leisure activities
It is important to know the individual's occupation and the kind of postural stresses it entails. Do they spend their day mostly sitting, driving or bending forwards? Are they constantly changing activity?
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CHAPTER TEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYAre they on their feet most of the timet We wish to know the pre
dominant activities of their working hours so that detrimental daily loading factors can be eliminated or lessened. Also it is useful to know if there has been a recent change in occupation, from a sedentary to a more manual job, or vice versa. Either change may be a trigger to potential overloading.
We also want to know about their usual sporting or recreational activities outside of work. Do they exercise regularly, or do they lead a largely sedentary life? Hobbies might include largely sedentary activities, such as fishing or knitting, so questioning needs to ensure that all types of pastimes are included.
Functional disability
We wish to know if the patient is off work at present, and/or not participating in any of their usual sporting or leisure activities because of their neck problem. The earliest possible return to full normal function is the suitable goal for management. The worker should be encouraged to remain at work or to return as soon as possible. The common misconception that they should be pain-free before returning to work should be addressed. Return to work should be a primary outcome of treatment.
Equally we should be aware of any normal sporting or recreational activities that they have stopped because of neck pain. An early return to such activities, possibly in a gradual way, should be encouraged as soon as possible. General fitness has a therapeutiC as well as protective effect for spinal pain, and management of the patient should address these issues.
Knowledge of the activity limitations that neck pain has caused in the patients normal lifestyle provides some understanding of their response to the problem in terms of their fear and anxiety. A brief and temporary interruption of normal activity may be necessary in some episodes; a long-term abstention from normal activity is unnecessary and disproportionate. Persistent avoidance of daily routines often indicates an exaggerated and inappropriate response to pain. Such patients need specific encouragement to return to normal activities and care must be made not to further exaggerate such inappropriate fear-avoidance behaviour.
THE HISTORY
Symptoms this episode
Where have you had symptoms this episode?
Where have you had pain or aching?
Have you had any pins and needles, tingling or numbness?
Have you had any weakness in the arm?
Where are you still having symptoms?
All the symptoms that have occurred during the present episode should be accurately marked on the body chart. To ensure accuracy this can be shown to the patient and checked by them. The relevant symptoms are those that have been felt in the last few days and are still a problem - these are noted on the line below. Baseline symptoms, which are still troubling the patient, must be recorded in full so that any changes in pain pattern over time can be appreciated.
We wish to know if the present pain is centraVsymmetncal or unilateraV asymmetrical. If symptoms are unilateral or asymmetrical, is the pain felt in the neck and arm, or is it referred below the elbow? We wish to know the most distal extent of any pain. If the patient reports pain in the arm or forearm, they should be asked if 'pins and needles', tingling or numbness are present at any time, and exactly where;
also if they have experienced any noticeable weakness in the arm. In later chapters management is described relative to different symptom patterns (Table 10. 1).
Table 10.1 Symptom patterns relevant to management decisions symmetrical pain
asymmetrical +/- pain to elbow
asymmetrical pain or paraestheSia below elbow.
The location of pain provides various useful pieces of information.
Central or bilateral symptoms invariably need sagittal plane proce
dures. Patients with unilateral symptoms may require lateral forces in their management, although their response to sagittal plane forces is generally tested first.
The extent and degree of referred or radiating pain and other symptoms gives some indication of the severity of the problem. More peripheral referral of symptoms, as well as the presence of paraestheSia or marked focal weakness, both of which may accompany symptoms referred below the elbow, tend to indicate a more severe problem.
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CHAPTER TEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYIf the location of pain has changed since onset, this may provide a clue to the status of the condition. Pain that was felt into the arm and is now felt only in the neck demonstrates an improving situation.
Conversely, pain that began in the neck and has gradually spread down the arm demonstrates a worsening situation.
The location of pain gives some insight into mechanical syndrome classification. The pain experienced with the dysfunction and postural syndromes is almost always felt locally, with no radiation of pain. An exception to this is referred pain caused by an adherent nerve root, which is described later. If pain radiates into the arm or forearm, a derangement is likely.
Nerve root involvement is possible if pain is described in the typical pattern of a dermatome (Slipman et a1.l998), especially when other neurological signs are present. Paraesthesia of diagnostic significance most commonly occupies the distal end of the dermatome; the patient reports tingling or numbness - C6 the thumb, C7 the middle finger, C8 the little finger. Less commonly C5 or T1 are involved - sensory loss occurring on the lateral border of the arm and the medial border of the forearm just below the elbow respectively (Kramer 1990; Butler 2000). It is not uncommon for there to be individual variation from the typical patterns.
There is ample room for confusion between symptoms that emanate from the cervical spine, the thoracic spine and shoulder problems - pain patterns may provide some clues. Several studies have indicated that pain around the scapular and shoulder region commonly arises from cervical discogenic or zygapophyseal joint disorders (Cloward 1959; Smith 1959; Whitecloud and Seago 1987; Grubb and Kelly 2000; Dwyer et al. 1990; April! et al.1990). However, stimulation of thoracic structures has also caused pain in the chest and scapular region (Bogduk 2002b). Irritation of the acromioclavicular joint (AC]) and subacromial space suggests that these structures may refer proximally, but that predominantly symptoms are felt either over the AC] or around the shoulder (Gerber et al. 1998). Any combination of neck and scapular or shoulder pain is thus most likely to be referred pain from cervical structures.
When did this present episode start?
This question is to determine when this particular episode staned. If the patient has suffered recurrent problems, at this stage we are only
THE HISTORY
interested in the present attack. Very often the patient is aware of the time an episode started. If pain has been present for a long time, an acute exacerbation of a chronic problem may have caused them to seek help. In this case the episode has lasted since the original onset.
It is helpful to know if we are dealing with an acute, sub-acute or chronic problem. In this text these are defined in line with the Quebec Task Force definitions (Spitzer et al. 1987), which correspond with the known healing process.
Table 10.2 Definitions of acute, sub-acute and chronic acute - less than seven days
sub-acute - between seven days' and seven weeks' duration chronic - more than seven weeks' duration.
The length of time that the condition has been present may give some indi.cation of the stability of the problem. Acute problems can easily be worsened as well as improved, so care with movement testing may be necessary. Acute and sub-acute problems are most probably due to derangement, whilst any three of the mechanical syndromes could be the cause of chronic problems.
Knowing the length of time that the problem has been present allows us to determine the state of the tissues. Days after onset tissues may be damaged and inflamed, whereas a few weeks later tissues may be healing. If the symptoms have been present for a couple of months, adaptive changes may have occurred in the collagenous repair tissue indicating that dysfunction may be the cause of persisting symptoms. If the problem has been present for many months, although a straightforward mechanical condition may be present, the chance that the tissues are hypersensitive and deconditioned should be borne in mind 00hnson 1997) Chronic pain syndromes often complicate the management of persistent pain and may, although not always, make treatment less effective. Pain that has been present for many months as well as having a poorer prognosis may respond more slowly if it does respond. Many patients have a long or recurrent history of their problem and therefore the educational component of management is particularly important to improve their future self-care. The duration of the episode thus provides diagnostic and prognostic information.
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CHAPTER TEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYThe length of time that the patient has had symptoms can also gUide us in deciding how vigorous we can be with mechanical assessment procedures. If a patient has had symptoms for several months and has been able to work or remain active during this time, he or she will probably have placed more stress on the structures at fault than we are likely to apply during our assessment process. This allows us to be fairly vigorous with the overall mechanical assessment. However, someone who presents with a very recent onset needs to be examined with more care, at least initially.
Is it getting better or worse or is it staying the same?
It is important to know if the patient thinks their problem is improving, worsening or unchanging. Judgements about the status of a condition may be based on five criteria (Table 10.3). A true understanding of the patient's condition comes from both the history and the physical examination. Only some of the information will be gained during the history-taking. If the patient volunteers that the condition is getting better or worse, it is important to confirm what they mean by this against some of the criteria outlined below.
Table 10.3 Criteria for defining status of condition Criteria
When the patient reports that their condition is improving, a review of the problem and its prognosis is often all that is required. Avoid the inclination to embark on a programme of passive therapies. If history and evaluation of repeated movements confirm the process of recovery is under way, continuing at a steady rate, and accompanied at the same time by improvement in function, there is no justification for any intervention other than education and assurance, unless or until progress comes to a halt. Provide gUidelines for the progression of activity and exercise and give advice on posture where necessary, but such patients do not need to attend a clinic for regular 'treatment'.
THE HISTORY
If the pain is unchanging, a routine approach to the assessment can proceed Stable and persistent symptoms generally permit a reasonably vigorous approach to assessment and management. Derangement or dysfunction may cause pain and functional impairment that may continue unabated for weeks or months, and may only be exposed using vigorous procedures.
If the patient reports pain that has persisted for many months, which may be constant or intermittent, and classification according to one of the mechanical syndromes is unclear, then a chronic pain syndrome may be suspected. Getting such patients started on regular, graduated exercise programmes frequently leads to an improvement in symptoms, function and patient's perceived self-efficacy Initially they may experience an exaggeration in symptoms due to the nature of chroniCity, which is likely to involve sensitisation of certain tissues.
They should be encouraged to pace their activities, not do too much too soon, and alternate activity with rest. Unless findings emerge from the assessment process that suggest further tests or more caution is reqUired, education and instruction in a vigorous self-treatment programme are indicated. Clinician intervention at this point is unnecessary, but may follow at a later date should self-treatment and gUidance fail to provide improvement.
In the event that the patient describes that his or her symptoms are worsening since onset, it is necessary to investigate the cause of deterioration. A rather gentle approach to the mechanical evaluation is always required if the patient describes that their pain is progreSSively increasing, and symptom response must be very carefully monitored.
Under these circumstances a purely educational approach may be indicated, certainly for the first twenty-four to forty-eight hours.
Sustained positions may be of more use than repeated movements in attempting to improve symptoms. Increasing pain intensity could indicate more serious pathology, but certainly indicates an unstable condition in which greater care should be taken.
Patients whose symptoms are worsening should be seen on a regular basis until stability or improvement occurs, or until it becomes obvious that referral for further investigation is necessary If the patient describes any of the 'red flag' indicators of serious pathology, or if the reactions to mechanical evaluation are atypical or if they fail to affect the symptoms, referral for further investigation should be considered.
For instance, an insidiously worsening neck pain in an older patient
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CHAI'TERe TEN THE CEReVICAL & THORcACIC SPINE: MECHANICAL DIAGNOSIS & THERcAPYwho reports being unwell should be the cause of some concern.
Appropriate blood tests or radiological assessment may shed light on the origin of the symptoms in such cases.
How did the neck pain start?
We want to know what the patient was doing when the pain started.
We want to know what the patient was doing when the pain started.