Spinal ependymoma presenting as subtle neurological findings in a VA chiropractic clinic: a case report in differential diagnosis and appropriate use of diagnostic imaging.

Background: Lhermitte's sign is a nonspecific historical and exam finding that carries with it a differential diagnosis of cervical myelopathy, multiple sclerosis, intradural tumors, or other central nervous system pathology. Regardless of the suspected diagnosis, further diagnostic investigation is indicated to determine etiology of symptoms. Case presentation: In this case, a 67-year-old male Veteran presents to a Veterans Affairs (VA) outpatient chiropractic clinic with an insidious 6-month onset of neck pain with historical description of a positive Lhermitte's sign, a single episode of bladder incontinence, and mild changes in upper extremity manual dexterity. These subtle historical findings prompted referral for a brain and cervical spine MRI, revealing an ependymoma in the cervical spine. Urgent neurosurgical referral was made, and the patient underwent C3-C7 laminectomy, C3-T2 fusion, and tumor resection. Summary: This case represents an example of clinical reasoning in a VA chiropractic clinic when presented with subtle neurologic findings, and discusses the differential diagnoses and decision-making process to pursue imaging that resulted in appropriate neurosurgical management.

Provider-patient communication: an illustrative case report of how provider language can influence patient prognosis.

Patient-provider communication can lead to unhelpful ideas and beliefs about a patient's condition, negatively impacting their clinical outcome. A 34-year-old male Veteran presented for an evaluation of high impact chronic low back pain. Previous interactions with various healthcare providers resulted in the Veteran viewing his condition as ominous and in need of intervention, however clinical findings did not support these beliefs. Our Veteran underwent six visits in the chiropractic clinic with treatment consisting of pain education, utilization of cognitive behavioral principles, active home care exercises and spinal manipulation, resulting in improvements in functional and objective outcome measures. This case report highlights the impact of misalignment between an early contact healthcare provider and patient misunderstanding of their condition on long term outcomes. It serves as an example of how physicians utilizing pathoanatomic explanations to describe a patient's chronic low back pain diagnosis can alter the patient's beliefs about their condition.

La communication entre le fournisseur de soins de santé et le patient peut conduire à des idées et à des croyances inutiles sur l'état du patient, ce qui a un impact négatif sur son résultat clinique. Un vétéran de 34 ans s'est présenté pour une évaluation d'une lombalgie chronique à fort impact. Des interactions antérieures avec divers fournisseurs de soins de santé ont amené le vétéran à considérer son état comme inquiétant et nécessitant une intervention, mais les résultats cliniques n'ont pas appuyé ces croyances. Notre ancien combattant a effectué six visites à la clinique chiropratique subissant chaque fois un traitement consistant en une éducation à la douleur, l'utilisation de principes cognitivo-comportementaux, des exercices de soins actifs à domicile et des manipulations vertébrales, ce qui a entraîné des améliorations dans les mesures de résultats fonctionnels et objectifs. Ce rapport de cas met en évidence l'impact d'un mauvais alignement entre un fournisseur de soins de santé de premier contact et l'incompréhension du patient de son état sur les résultats à long terme. Il sert d'exemple de la façon dont les médecins utilisant des explications d'anatomie pathologique pour décrire le diagnostic de lombalgie chronique d'un patient peuvent modifier l'idée que se fait le patient de son état.

Yoga vs Stretching in Veterans With Chronic Lower Back Pain and the Role of Mindfulness: A Pilot Randomized Controlled Trial.

OBJECTIVE: The purpose of this study was to investigate the feasibility of recruiting, randomizing, enrolling, and collecting outcome data on veteran patients with chronic low back pain (CLBP) who undergo an 8-week, active exercise class with mindfulness (yoga class) and without (stretching class). METHODS: United States veterans with CLBP based on inclusion/exclusion criteria were randomized to 1 of 2 groups. The study design was a pilot randomized controlled trial. Twenty CLBP patients attended a yoga class or stretching class once per week for 8 weeks at the Veterans Affairs Rochester Outpatient Center, Rochester, New York. The following measurements were obtained: recruitment or enrollment data, compliance data to include class attendance and home exercise, and compliance data regarding ability to collect outcome measures at baseline and at completion. Outcome measures included pain (PEG), quality of life (PROMIS Global Health Survey), self-efficacy (2-item questionnaire), fear avoidance belief, catastrophizing, and social engagement in addition to qualitative clinician open-ended questions postintervention. RESULTS: Forty-five veterans were queried regarding interest in participation. Of these, 34 (76%) met the study's criteria. Twenty (44%) agreed to participate and were consented, randomized, and enrolled in the study. Initial and final outcome measures were obtained for each participant (100%). Forty percent attended more than 80% of the sessions for both yoga and stretching groups. CONCLUSION: This pilot study demonstrated feasibility of recruiting, enrolling, and collecting outcome data on CLBP veteran patients participating in yoga and stretching class. The data from this pilot will inform the development of a randomized, comparative effectiveness study of yoga with and without mindfulness in the management of CLBP.