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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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was smooth.
Given the clear evidence of sudden deterioration in neurologic status,
cervical MRI was performed before any further care (particularly, regional
manual treatment) was considered. MRI demonstrated a large left parasagittal
and lateral C6-C7 disk herniation with extension into the neural foramen, and
cervical cord compression and displacement without signal intensity change
or substantial bony neuroforaminal or central canal narrowing. A spine
surgical consultation was accommodated almost immediately. The patient
was treated with a single-level anterior cervical decompression and fusion.
Surgical considerations notwithstanding, this patient’s best outcome
clearly extends beyond root decompression and segmental fusion; her history
and clinical findings were demonstrative of a long-standing movement
disorder and postural stress relative to more chronic axial neck and back pain
and shoulder stiffness. Transdisciplinarity afforded a seamless transition to
postoperative management of pain and stiffness and care of her preexisting
dysfunctional axial and shoulder girdle stabilization mechanics. Treatment of
all conditions was equally critical to an optimal outcome.
Case Example Two
A 29-year-old woman employed as a professional singer and administrative
assistant requested a chiropractic evaluation. She reported more than 10 years
of neck and upper back pain and generalized (symmetric suboccipital to
bitemporal distribution) headaches. She denied other symptoms, and a review
of systems and medical history were reportedly otherwise unremarkable. She
did not exercise and maintained a multiyear smoking habit of one pack of
cigarettes per day.
Although the patient had undergone monthly full spine chiropractic
manipulations for several years, she acknowledged no more than temporary
benefit from these treatments. She had not been examined by a physician or
physical therapist for her current symptoms. She admitted to depression
regarding her persistent symptoms and anxiety about degenerative changes
noted on her cervical radiographs.
She had a dysphoric, asthenic, and fatigued appearance with slouched
posture. The patient was intermittently tearful during her appointment.
Widespread tenderness was reported with even superficial palpation, which
resulted in a withdrawal response. No focal midline or anterior neck
tenderness was elicited.
Passive neck motions were grossly physiologic, with pain in all planes
but primarily in extension, with associated upper thoracic stiffness and
discomfort. The Spurling test result was negative for radicular-type
symptoms; however, neck pain was elicited with even light vertex pressure,
indicating a positive axial loading test result. Deep neck flexor recruitment
was suboptimal with anterior head carriage. Bilateral shoulder ranges of
motion were full and locally painless, and clinical examination showed no
finding suspicious for rotator cuff, bicipital tendon, or glenoid labral
compromise. Scapulothoracic motions were grossly normal. Upper extremity
neuromotor, reflex, and sensory examinations were normal without neural
tension or long tract signs. After the examination, the patient’s relatively
benign findings were explained and she was reassured that further diagnostic
testing was unnecessary. She was distressed, expressing that she hoped to
undergo MRI to determine the cause of her symptoms.
A transdisciplinary approach was recommended, including physical
therapy, physiatric evaluations, and brief but time-limited regional manual
treatment. The behavioral findings were addressed with careful inquiry into
any unreported prior injury. The patient volunteered a history of sustained
sexual, physical, and emotional abuse during late childhood, for which she
had never received counseling. Her pain was explained in the context of
chronicity, central processing, and a lack of supportive mental health care.
Additional physical treatments were contingent on coordinated psychologic
assessment, to which the patient agreed.
The patient reported substantial improvement in all symptoms in a matter
of weeks. Manual therapy was withdrawn and further gains were reported at
follow-ups over 6 months, during which psychologic counseling continued.
She reported increasing optimism regarding her ability to effectively selfmanage symptoms by means of spine stabilization exercises, relaxation
techniques, and walking. Her sleep had improved, and she was willing to
transition to self-directed care. Two years later, she returned with a flare-up
in symptoms after experiencing strain while lifting during a household move
and confirmed general successful independent management of her symptoms
with a continuing exercise program. Tobacco use had continued, but at
decreased levels, and she reported improvement in anxiety and depression
while continuing mental health care at an outside facility.
What Can We Learn?
These two case examples represent relative extremes on the spectrum of neck
pain disorders. The first case is a well-defined instance of acute-onset
neurologic compromise, and the second case involved nonspecific physical
finding in a patient with prevalent long-standing psychosocial distress,
unnecessary treatment dependency, and a history of abuse that strongly
correlated with progression to chronic pain. Neither patient had previously
received evidence-oriented clinical care. From a strictly biomedical
perspective, both patients were ostensibly candidates for physically oriented
treatment (stand-alone surgery in the first case and extensively repetitive
chiropractic treatments in the second case) without prior consideration of the
broader clinical pictures. Critical to care optimization was transdisciplinary
recognition of a combination of physical and psychosocial factors that if
unaddressed may have resulted in unnecessary physical treatments, poor
outcomes, and significant patient ramifications.
These examples demonstrate the broad changes that confront the future of
orthopaedic practice and “significant cooperation on behalf of all involved
healthcare providers will be necessary to ensure that quality of care does not
suffer while efforts for cost containment continue”54 and the emerging
realization that transdisciplinarity will be critical to patients and providers
negotiating a new era in health care.
Summary
The current approach to cervical spine care is unsustainable. Cervical spine
disorders are endemic, highly recurrent, and commonly involve psychosocial
and other complexities that exceed the management capacity of any single
spine specialist. Compounded by the extraordinary internal and external
stresses of a rapidly changing healthcare environment, transdisciplinarity is
urgently needed in patient care. Although efforts to refine physical treatment
should continue, transdisciplinarity in health care has the potential to improve
outcomes, patient satisfaction, and treatment value and enhance the work
experience of providers.
Embracing and implementing a transdisciplinary biopsychosocial care
model requires a willingness to think and work in new ways. A chaordic
model of management may hold the key to this evolution in health care.
Key Study Points
Cervical spine disorders are highly prevalent, with substantial personal and
societal costs.
Extant management models have resulted in neck care that is largely
biomedical, expensive, poorly coordinated, and ineffective.
Psychosocial factors are equally, if not more, influential on treatment
outcomes and the progression to neck pain disability. Broad access to
biopsychosocial neck care is needed.
Despite some single-treatment effectiveness, the scope of cervical
disorders exceeds that of any single discipline.
Transdisciplinary health care has the potential to expedite access while
improving outcomes, value, and patient satisfaction.
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individuals with neck pain.
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Prior to commencing rehabilitation in cases of unexplained chronic musculoskeletal
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cognitions and reconceptualize pain. This can be accomplished by patient education
about pain physiology, a continuous process initiated during the educational sessions
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multidisciplinary approach is maintained.
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A screening and targeted approach was found to be more effective and cost-effective in
treating low back pain than current best practice. Three different interventions targeted
patients identified at low, medium, or high risk depending on the presence of
psychosocial risk factors. The authors describe the development and content of the
STarT Back trial’s high-risk intervention in the context of a systematic approach,
termed psychologically informed practice.
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early physical therapist management of neck pain: A retrospective cohort analysis.
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This study found that healthcare systems that provide pathways for patients to receive
early physical therapy for neck pain may realize improved patient outcomes, greater
value, and higher efficiency in decreasing disability and pain compared with delayed
management. Additional studies are needed.
of clinicians at a functional restoration program. J Occup Rehabil 2011;21(1):1-8.
This study reported that transdisciplinary teams with multiple healthcare providers are
suitable for treating patients with complex needs and with chronic injuries. Input from
organizational and communication levels is required to effectively contribute to both
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