A multimodal physical therapy approach to the management of a patient with temporomandibular dysfunction and head and neck lymphedema: a case report

Objective and importance:

There is a paucity of research that investigates therapeutic interventions of patients with concurrent head and neck lymphedema and temporomandibular dysfunction (TMD). The purpose of this case report is to describe the management and outcomes of a patient with head and neck lymphedema and TMD using a multimodal physical therapy approach.

Clinical presentation:

A 74-year-old male with a past medical history of head and neck lymphedema and TMD was referred to physical therapy with chief complaints of inability to open his mouth in order to eat solid food, increased neck lymphedema, temporomadibular joint pain, and inability to speak for prolonged periods of time.

Interventions:

The patient was treated for three visits over 4 weeks. Treatment included complete decongestive therapy (CDT), manual therapy, therapeutic exercise, and a home exercise program. Upon discharge, the patient had improved mandibular depression, decreased head and neck lymphedema, improved deep neck flexor endurance, decreased pain, and improved function on the Patient Specific Functional Scale (PSFS).

Conclusion:

Utilization of a multimodal physical therapy approach to treat a patient with a complex presentation yielded positive outcomes. Further research on outcomes and treatment approaches in patients with TMD and head and neck lymphedema is warranted.     

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.     

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.     

A rare case of sigmoid colon obstruction in patient with ulcerative colitis: role of transabdominal ultrasound-guided biopsy

Introduction

Endometriosis is a common chronic gynaecological disease affecting 10 % of women of reproductive age. Of these 5–12 % may present bowel endometriosis that may be asymptomatic or associated with aspecific symptoms even bowel obstruction.

Case presentation

The case of a 41-year-old woman with history of ulcerative colitis, previous diagnosis of ovarian endometriosis, recurrent abdominal pain not related to the menstrual cycle, with abdominal pain and obstinate constipation for 2 weeks was referred. The patient underwent colonoscopy, transabdominal ultrasound and ultrasound-guided fine-needle biopsy to have a diagnosis.

Discussion

Endometriosis should be considered in the differential diagnosis of every woman of childbearing age who presents with gastrointestinal or abdominal symptoms. As demonstrated in our case and by the burgeoning literature in this field, we believe that the role of transabdominal ultrasound should be reconsidered in the management of abdominal diseases because this examination associated with ultrasound-guided fine-needle biopsy allows, in expert hands, to obtain adequate histological samples avoiding patients to undergo more invasive tests to get a diagnosis.     

Diagnoses of anxiety and depression in clinical-scenario patients: Survey of Saskatchewan family physicians

Objective

To investigate family physicians’ differential diagnoses of clinical-scenario patients presenting with symptoms of either generalized anxiety disorder (GAD) or a major depressive episode (MDE).

Design

Cross-sectional survey.

Setting

Saskatchewan.

Participants

A total of 331 family physicians practising in Saskatchewan as of December 2007.

Main outcome measures

Type and number of physicians’ differential diagnoses for a GAD-scenario patient and an MDE-scenario patient.

Results

The survey response rate was 49.7% (331 of 666 surveys returned). Most physicians suggested a diagnosis of anxiety (82.5%) for the GAD-scenario patient and a diagnosis of depression (84.2%) for the MDE-scenario patient. In descending order, the 5 most frequent differential diagnoses for the GAD-scenario patient were anxiety, hyperthyroidism, depression, panic disorder or attack, and bipolar disorder. The 5 most frequent differential diagnoses for the MDE-scenario patient were depression, anxiety, hypothyroidism, irritable bowel syndrome, and anemia. Neither a diagnosis of anxiety nor a diagnosis of depression was associated with physicians’ personal attributes (sex, age, and years in practice) or organizational setting (number of total patient visits per week, private office or clinic, solo practice, Internet access, and rural practice setting). However, physicians in solo practice suggested fewer differential diagnoses for the GAD-scenario patient than those in group practice; physicians in practice 30 years or longer suggested fewer differential diagnoses for the MDE-scenario patient than those in practice fewer than 10 years. On average, physicians suggested 3 differential diagnoses for each of the scenarios.

Conclusion

Most family physicians recognize depression and anxiety in patients presenting with symptoms of these disorders and consider an average of 3 differential diagnoses in each of these cases.     

Predictors of persistent neck pain after whiplash injury

Objective

To establish the aetiological influences of persistent neck pain following a motor vehicle collision and to construct a model for use in the emergency department for identifying patients at high risk of persistent symptoms.

Design

Prospective cohort study. Patients recruited from hospital emergency departments were sent a questionnaire to gather information on various exposures. They were followed up at 1, 3, and 12 months to identify those with persistent symptoms.

Main outcome measure

Persistent neck pain (pain at 1, 3, and 12 months after collision).

Results

The baseline survey included 765 patients. Subsequently, 480 completed a questionnaire at each follow up time point, of whom 128 (27%) reported neck pain on each occasion. Few collision specific factors predicted persistent neck pain. In contrast, a high level of general psychological distress, pre‐collision history of widespread body pain, type of vehicle, whiplash associated symptoms, and initial neck disability best predicted the persistence of symptoms. Furthermore, these factors, in combination, accounted for more than a fivefold increase in the risk of persistent neck pain.

Conclusion

The greatest predictors of persistent neck pain following a motor vehicle collision relate to psychological distress and aspects of pre‐collision health rather than to various attributes of the collision itself. With these factors, and those relating to initial injury severity, it is possible to identify a subgroup of patients presenting with neck pain with the highest risk of persistent symptoms. Thus, it is possible to identify whiplash patients with a poor prognosis and to provide closer follow up and specific attention to management in these individuals.     

Point of care ultrasound (POCUS) telemedicine project in rural Nicaragua and its impact on patient management

Background

Point of care ultrasound (POCUS) is a useful diagnostic tool in medicine. POCUS provides an easy and reproducible method of diagnosis where conventional radiologic studies are unavailable. Telemedicine is also a great means of communication between educators and students throughout the world.

Hypothesis

Implementing POCUS with didactics and hands-on training, using portable ultrasound devices followed by telecommunication training, will impact the differential diagnosis and patient management in a rural community outside the United States.

Materials and methods

This is an observational prospective study implementing POCUS in Las Salinas, a small village in rural western Nicaragua. Ultrasound was used to confirm a diagnosis based on clinical exam, or uncover a new, previously unknown diagnosis. The primary endpoint was a change in patient management. International sonographic instructors conducted didactic and practical training of local practitioners in POCUS, subsequently followed by remote guidance and telecommunication for 3 months.

Results

A total of 132 patients underwent ultrasound examination. The most common presentation was for a prenatal exam (23.5 %), followed by abdominal pain (17 %). Of the 132 patients, 69 (52 %) were found to have a new diagnosis. Excluding pregnancy, 67 patients of 101 (66 %) were found to have a new diagnosis. A change in management occurred in a total of 64 (48 %) patients, and 62 (61 %) after excluding pregnancy.

Conclusion

Implementing POCUS in rural Nicaragua led to a change in management in about half of the patients examined. With the appropriate training of clinicians, POCUS combined with telemedicine can positively impact patient care.     

Ultrasound picture of a wooden splinter evolved in phlegmon of the hand

Introduction

To demonstrate the usefulness of ultrasound (US) in quickly and effectively diagnosing the presence of a foreign body in the superficial soft tissues.

Materials and methods

A young lumberjack underwent US examination due to pain and swelling of the back of his right hand. These symptoms are often due to the presence of a wooden splinter.

Results

On the back of the right hand, US demonstrated a hyperechoic line with acoustic shadowing surrounded by a hypoechoic halo suggesting a foreign body. Next to it in the same area, several hypoechoic areas were observed.

Conclusions

US can quickly identify the exact position of a foreign body embedded in the skin and soft tissues; US can furthermore provide information about the inflammatory process and its spreading.     

High frequency of McKenzie��s postural syndrome in young population of non-care seeking individuals

Objectives

The role of postural loads as a risk factor for back pain and musculoskeletal symptoms is unclear. McKenzie proposed in his classification of mechanical syndromes a postural syndrome, in which people only develop symptoms from sustained loading, which is relieved by a change in position and has no effect on movement or function. Because of the low level disability with postural syndrome, it was suggested that few seek healthcare for this problem.

Methods

This study used a two-stage process first to give a questionnaire to 100 students and staff from a university to determine who appeared to have postural syndrome, and then applied a physical examination to those who consented.

Results

One hundred and thirty-eight were approached, of who 100 completed questionnaires and 66% appeared to have postural syndrome. Of the 66 who appeared to have postural syndrome, 37 consented to have a physical examination. Of the 37, 31 met the criteria for postural syndrome, with postural syndrome being significantly associated with pain on sustained loading and pain abolition on posture correction. Most postural syndrome was in the lumbar spine and associated with sitting, but other sites and causes were also noted.

Discussion

This study lends credibility to McKenzie’s postural syndrome, but also suggests this as a possible precursor for future more disabling or painful problems. Postural syndrome may not feature in those seeking professional healthcare, but is clearly highly prevalent in a young population.     

Multiple Sclerosis Presenting as a Delirium: A Case Report

Objective

To report a case of multiple sclerosis (MS) with delirium as the first presentation.

Clinical Presentation and Intervention

A 34-year-old female was referred to our department with an acute onset of drowsiness, withdrawal from routine activities and aggression, followed by neurologic deficits after a couple of days. Clinical and radiographic examinations were performed, leading to the initial diagnosis of MS. A vast range of differential diagnoses was excluded to confirm the diagnosis of MS.

Conclusion

Neurological examination and appropriate imaging enabled the diagnosis of MS with delirium in this patient followed by the appropriate treatment.Key Words: Multiple sclerosis, Delirium, Plasmapheresis