L32: Multidisciplinary management of cervical and thoracic disorders

Question 1

What are 5 clues/red herrings?

Answer 1

1. Cardiovascular risk factors (hypertension, dyslipidemia, obesity, and age greater than 45 years old) => moderate risk for cardiovascular disease; adding in pain in the neck that ‘may result from ischemia’ => high risk.
2. Abnormal ECG prior to thyroidectomy
3. Two physicians said a cardiovascular issue could be possible. No-one had followed up on this.
4. Degenerative findings on neck Xray assumed to be the cause even though history and clinical exam did not point to mechanical pain.
5. Cervical abnormalities highly prevalent in imaging, even in asymptomatic individuals.

Question 2

What are 8 characteristics of angina pectoris?

Answer 2

1. Anterior neck pain can be a symptom of angina pectoris caused by coronary artery disease.
2. Typically crushing, squeezing, or heavy pain in the chest area.
3. Anterior neck (throat) pain less common presentation
4. Left arm pain, interscapular and chest pain are much more readily recognizable
5. Pain caused by lack of blood flow (ischemia) to the heart and may precede myocardial infarction.
6. Pain referred to neck and jaw (convergence of afferent input onto cervical spinothalamic tract at C1–C3 level, effecting somatic receptive fields of these levels)
7. Spinal level that receives visceral sensation from the heart simultaneously receives cutaneous sensation from parts of the skin specified by that spinal nerve’s dermatome, without an ability to discriminate the two.
8. Can be accompanied by shortness of breath, dizziness, and fatigue, but also occurs alone.

Question 3

What are 4 clinical reasoning mechanisms led to successful differential diagnosis?

Answer 3

1. Early on, pattern recognition to determine that the neck pain fell outside of typical presentation of mechanical neck pain.
2. Later, mental ‘time-out’ to reflect on data that had been collected. Meta-cognition allowed PT to recognize that a working diagnosis of mechanical neck pain not supported by any clinical findings.
3. Systematic approach to attempt to further elicit the pain during exercise.
4. Confident rejection of initial hypothesis of mechanical neck pain for more feasible diagnosis of nonmechanical pain.

Diagnostic tools to minimize error such as pattern recognition, meta-cognition, mental checklists of differential diagnoses and red flags, and openly discussing misdiagnosis among peers imperative.

Question 4

To make a correct differential diagnosis, it is necessary to practice ‘_______ ’ thinking and be knowledgeable about common diagnostic errors.

Answer 4

worst-case scenario

Question 5

What are 7 characteristics of multidisciplinary team approach?

Answer 5

1. Good communication between the doctor and the physiotherapist
2. A team approach beneficial for the patient with a neck disorder
3. Medical management and physiotherapy are complimentary
4. Patients can present to physiotherapists as first contact practitioners, communication with the doctor is professional etiquette, red flags - refer back to Dr, etc.
5. Work with the GP or other specialist to communicate PT plan and appropriately request alternate medication or onward referral.
6. How to approach and communicate with GPs
7. Sometimes communication has not been optimal

Question 6

What are 8 other health professionals in the multidisciplinary team?

Answer 6

1. Some may need just GP – pain, order other tests, referral to others
2. Neurologist - migraine, nerve conduction studies
3. Pain specialist - RFN, facet joint injections etc.
4. Multidisciplinary Pain clinic
5. Cardiologist - VBI, VAD/CAD - MRA Magnetic resonance angiograph
6. ENT - Dizziness, vertigo
7. Vestibular physiotherapist
8. Neurosurgeon – radiculopathy, myelopathy
9. Surgery - rare
10. Psychologist – stress management, CBT

• Know when physios should refer back to GP for additional support such as more appropriate drug management, or diagnostic tests: red flags, slow or no response to therapy, pain not controlled
• When patient might need onward referral to more specialist care or imaging

Question 7

What are 7 characteristics of patient interview/ physical examination?

Answer 7

1. Does it all add up?
2. Do I need to ask more questions?
3. Do I need to do more tests ?
4. Do I need to refer on? – when?
5. Is this serious - immediate referral ?
6. Are there any precautions / contraindications?
7. Things to be aware of / monitor for

Question 8

What are 7 disorders that might stimunlate cervical spinal pain?

Answer 8

1. Malignant / benign lymphadenopathy
2. Pancoast tumor
3. Vertebral artery
4. Subarachnoid haemorrhage
5. Coronary artery disease
6. Polymyalgic rheumatica
7. Meningitis

Question 9

What are 8 disorders that might stimunlate thoracic spinal pain?

Answer 9

1. Bronchogenic carcinoma
2. Lung disease
3. Coronary artery disease
4. Aortic aneurysm
5. Cardiac enlargement
6. Hiatus Hernia
7. Gall bladder disease
8. Herpes zoster

Question 10

What are 6 cautions/contra-indications?

Answer 10

1. Bone weakness – disease, trauma, injury
2. Neurological: cord compression, cauda equina compression, nerve root compression with increasing neurological deficit
3. Vascular
4. Lack of diagnosis / undiagnosed pain
5. Compromised structural integrity of joints, spinal structures – disease, trauma, surgery, pregnancy
6. Visceral mimic pain

Question 11

_____ if unsure!

Answer 11

Refer on; Further investigations etc.

Question 12

What are 3 characteristics of GPs also assist with?

Answer 12

1. Radiological investigations – PTs can order plain x-rays of the spine but rebate may not be as good
2. Medication – PTs can consult with Dr re medication for potential pain mechanisms - Neuropathic vs Nociplastic
3. Interventional procedures

Question 13

What are 6 characteristics of radiology- plain X-ray?

Answer 13

1. Not indicated acute neck pain in absence of history of trauma
2. or in absence of clinical features of possible serious disorder.
3. Indicated neck trauma - Canadian C-Spine rule
4. What does presence of degenerative changes on x-ray
5. tell us?
6. What do we say to the patient?

Question 14

What are 6 indications of C-T scans?

Answer 14

1. Plain films are positive, suspicious or inadequate
2. Plain films are normal but neurological signs or symptoms are present
3. Screening films suggest injury at the occiput to C2 levels
4. There is severe head injury
5. There is severe injury with signs of lower cranial nerve injury
6. There is pain and tenderness in the sub-occipital region

Question 15

What are characteristics of MRI?

Answer 15

Acute neck pain in conjunction with features alerting to the possibility of a serious underlying red flag condition is an indication for MRI.

Question 16

What are 3 characteristics of medication for neck pain?

Answer 16

1. High initial pain levels are predictive of poor recovery following whiplash injury
2. Central hyperexcitability is a feature of whiplash (acute: ~30%), cervical radiculopathy but not idiopathic neck pain
3. Suggests that appropriate medication will be important – particularly for more severe neck pain conditions

Question 17

What are 5 characteristics of effective pain relief as a human right?

Answer 17

1. Unrelieved severe pain - adverse psychological and physiological effects.
2. Consumers should be involved in the assessment and management of their pain.
3. To be effective, pain treatment should be flexible and tailored to individual needs.
4. It should be possible to reduce pain to a comfortable or tolerable level.
5. Pain should be treated early, as established, severe pain is more difficult to treat.

Question 18

What are the NHMRC guidelines fo rmanagement of musculoskeletal pain?

Answer 18

Question 19

What are NSAIDS for MSK pain?

Answer 19

Question 20

What is neuropathic pain relief?

Answer 20

Question 21

What are stronger medications for MSK pain?

Answer 21

Question 22

What are 6 characteristics of zygapophyseal joint and medial branch nerve injections?

Answer 22

1. Z joint pathology
2. Differentially diagnose zygapophyseal joint pain from something else
3. Fluroscopy guided - mixture corticosteroid and anaesthetic
4. Some side effects
5. Medial branch block – safer but more diagnostic precursor to RFN
6. Need to do level above and below

Question 23

What are 3 characteristics of radio-frequency neurotomy (RFN)?

Answer 23

1. ~ 40% of chronic neck pain may arise from Z Jts – But highly selected whiplash population
2. Level II evidence that RFN is efficacious for neck pain of Z jt origin
3. Level II evidence that RFN is not efficacious for neck pain & cervicogenic

Question 24

What are injections for cervical radicular pain?

Answer 24

Injections

1. Transforaminal steroid injections- cervical epidural
   
   1. Risk of spinal cord injury or death (embolisation of steroids into radicular artery; vertebral artery)
2. Interlaminal
   
   1. Often 3 injections 2 weeks apart
   2. Best if guided radiologically

Nerve root blocks - Local anaesthetic injections similar effect

Question 25

What are 3 charcteristics of spinal cord stimulation? What is the indication?

Answer 25

1. Electrodes near dorsal column to modulate pain
2. Some side effects possible
3. Need careful patient selection

For chronic pain

Question 26

What is the RECOVER Injury Research Centre?

Answer 26

• RECOVER Injury Research Centre is a joint initiative of the
• Queensland Motor Accident Insurance Commission (MAIC) and The
• University of Queensland.
• RECOVER is a leading research centre based in Queensland,
• Australia.
• The mission of RECOVER is to produce breakthrough
• research which leads to better outcomes after injury, especially
• when caused by road traffic crashes.

Question 27

What are resources of clinicians?

Answer 27

1. WhipPredict: a risk stratification tool for whiplash
2. My Whiplash Navigator

Question 28

A physiotherapist-led intervention of stress inoculation training and exercise resulted in clinically relevant ______ in disability compared with exercise alone-the most commonly recommended treatment for acute WAD.

Answer 28

improvements

Question 29

What are 3 guideline-based clinical pathway of care?

Answer 29

1. Multi-centre, RCT in Queensland and New South Wales, of a clinical pathway of care, with care matched to predicted risk of poor recovery.
2. Participants at low risk of ongoing pain and disability => up to three sessions of guideline-based advice and exercise with their primary healthcare provider.
3. Those at medium/high risk => specialist practitioner with expertise in whiplash for more in-depth physical and psychological assessment and liaise with the primary healthcare provider to determine one of three further pathways of care.

Question 30

What are 2 characteristics of trauma-focused cognitive behavioural therapy and exercise?

Answer 30

1. Primary aim to investigate effectiveness of combined trauma-focused CBT, delivered by a psychologist, and physiotherapy exercise to decrease pain and disability of individuals with chronic whiplash and PTSD.
2. To investigate effectiveness of the combined therapy in decreasing PTSD symptoms, anxiety and depression.

Question 31

What is the pilot clinical trial of pregabalin and advice for WAD?

Answer 31

• Pregabalin (anti-epileptic) and an evidence based advice booklet (intervention)

versus

• placebo and the same evidence based advice booklet for individuals with acute WAD at risk of poor recovery.

There was significantly greater reduction in pain in the pregabalin group compared to placebo at 5 weeks