Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Another awesome infographic via Brad Beer!


Have arm or leg pain when driving? It's difficult to stretch or find a movement or position that relieves it. Here, Dr. Dana Palmer, part of our Modern Rehab Mastery Online mentoring cohort and myself go over accidentally found, but easy to perform solutions that may help your arm or leg pain/numbness.
Cranial nerve testing is BORING!
In entry-level physical therapy education, I remember learning (well, memorizing at the time) the cranial nerves.  We did everything we could to remember it including the most entertaining mnemonics 🙂
It never “stuck” with me to include this in daily clinical practice examination until I followed through with my Fellowship Program and specifically used it in a manner to rule-out conditions, specific conditions at that.
I enjoyed reading an article entitled, “Extracranial internal carotid artery aneurysm presenting as symptomatic hypoglossal and glossopharyngeal nerve paralysis” in The Journal of Laryngology & Otology in 2004.  Even though “old” in today’s standards for evidence-based practice, I want to point out the concepts that arise from the clinical reasoning and its relationship to Cranial Nerves and the Internal Carotid Artery. 
One concept I always push in our Cervicogenic Dizziness Course is that we need to be vigilant on the entire cervical vascular system and not just screening for Vertebrobasilar Insufficiency.  This ultimately means we need to know about signs/symptoms and clinical characteristics of disorders to the Internal Carotid Artery.  We can therefore, make sure we rule-out other sinister conditions to then aid in ruling-in Cervicogenic Dizziness as the diagnosis.




Cervical Vertigo. Cervicogenic Dizziness.
All Rights Reserved. Cervicogenic Dizziness. Optimal Sequence Algorithm. Integrative Clinical Concepts.

Just as described in our Optimal Sequence Algorithm, the first step prior to even assessing the vascular system, especially any mechanical disruption, is to go “back to basics”.
This involves initially examining the cranial nerves, especially the ones that may be affected first in a patient presenting with internal carotid artery dysfunction.
Cervicogenic Dizziness, Cervical Vertigo
A negative finding on cranial nerve examination is one of the presenting clinical findings that led the team in this paper to perform an ultrasound on the neck and then refer for MR imaging.
You may ask what led to performing cranial nerve exam. Here you go:
Here are the paper highlights:

Subjective

  • After a patient went to chiropractor for 3 visits 1 month prior, she self-admitted to ENT office for painful swelling in jaw .
  • She had several bouts of dizziness associated with turning her head to her left.
  • She had bouts of light-headiness.
  • She also developed loss of hearing in her left ear.

Objective

  • Odd sensation with swallowing
  • Marked tongue deviation to the right side with tongue protrusion




Cervicogenic Dizziness, Cervical Vertigo
Cervicogenic Dizziness Course

So how does this relate to Cervicogenic Dizziness?
  • The subjective findings above could mean mechanical or non-mechanical source of symptoms but objective findings indicate a cranial nerve palsy response to cranial nerve testing (specifically hypoglossal and glossopharyngeal).
  • Patient could have self-admitted to a physical therapy office instead of ENT, so ultimately we need to be able to fully examine someone with initial thoughts of non-mechanical symptoms unless proven otherwise.
  • Positional dizziness, such as turning head to the left, are typical symptoms associated with the diagnosis of Cervicogenic Dizziness.
  • Lightheadiness is a typical symptom associated with the diagnosis of Cervicogenic Dizziness.
  • She had a recent minor trauma, which in this case, was a trip to the chiropractor with assumption of a manipulation performed.
    • Instead of seeing another clinician, she could have simply had a recent minor trauma from looking up, played golf, or even had a concussion or in a car accident.
Even though the authors suggest there was a correlation with chiropractic manipulation prior to patient seeing ENT, it cannot be proven that the procedure was the cause of her cranial nerve palsy. In fact, her attacks of lightheadiness and pain worsened after initial visit to the ENT, who prescribed anti-biotics!  Another post on this coming in the future.  
Nevertheless, we recommend clinicians screen appropriately with subjective and objective examination procedures, especially if someone is presenting with symptoms of lightheadiness, dizziness and/or vertigo.

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  
If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.
Authors
Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Danielle N. Vaughan, PT, DPT, Vestibular Specialist  
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Keeping it Eclectic...


Always be wearing of people who say always, and never trust people who say never! Always! That's one of my favorite quotes, and it's especially true in the dogma of healthcare and tribalism that clinicians get caught up in. Brad Beer has an awesome infographic about 5 Foot Orthoses Myths that I posted below.

What are your thoughts? I used to make custom orthotics, then thought everyone needed to train barefoot, got caught up in that "Born to Run" phase, then per the normal progression, realized the middle ground is where you should stand on support, shoes, and orthotics.



Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

Learn more online!


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...


Hamstring "tightness" is mostly just perception and very rarely is it really a length issue. When active straight leg raise is limited/tight/painful and passive straight leg raise is significantly improved in mobility (but not necessarily intensity), you can easily reset it.

The JOSPT recently published (Sep 1, 2019) new Clinical Practice Guidelines for treating Patellofemoral Pain. Several years ago, these guidelines were mostly generic and exercise based, but more and more, are well researched and something you should review. Students who could use a refresher on treating knee pain should look at these latest CPGs.

Things that stand out and mesh well with The Eclectic Approach
  • use functional testing like a squat, single leg squat, step downs
  • manual therapy and taping should only be used in conjunction with exercise, taping beyond 4 weeks is not effective
  • categorization of patients who respond to hip/knee strengthening exercises, improvements in motor control, or mobility
  • ⁉️don't use dry needling? - but acupuncture is ok to use⁉️
  • modalities are not effective
Things that are still outdated
  • flexbility deficits of the lateral retinaculum or ITB⁉️⁉️⁉️ 


Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

Learn more online!


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...


Many patients (and clinicians) should get into regular habits of improving their overall health. Those with chronic issues, slow recovery, low energy, or multiple comorbidities can benefit from adding these activities to their daily schedule. Many times, the nervous system is ramped up and recovery is slowed down, leading to slow or non-responders. Improving overall health reduces the vigilance of the neuro immune system and mindfulness, regular exercise, 8 hours of sleep, and eating healthier can all help.



You need to train recovery just like you would for strength, performance, or fitness. When time and traditional rehab takes care of issues, not all of these things are needed. Overall, incorporating eating real foods (especially fiber), improving sleep quality and duration, and exercising regularly are things most people can do better. If you're not doing it yourself as a clinician, how do you expect your patients to follow through with these health changing strategies? 

We have an entire online seminar on Modern Patient Education - incorporating all of these strategies and how to maximize therapeutic alliance with a patient. Check it out below!

The Eclectic Approach to Modern Patient Education teaches everything you should have learned in school and most seminars! MPE50 coupon code gets you $50 until Sept 9, 2019 midnight EST!


Keeping it Eclectic...


Sometimes you can try your best, give your best positive message and you will be totally derailed by other clinicians giving a TERRIBLE negative message. Luckily, the patient's head was in the right place, despite her former PT and current ortho surgeon telling her to keep limiting her function, despite her continued improvements. Honestly, what are some providers thinking?




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Keeping it Eclectic...