 Today's case discussion, again, is nothing incredibly unique, but I decided to bring it forward due to some potential considerations for treatments. I should note that my student Britt did most of the evaluation, so several tests and measurements were left out that I normally perform. I did proceed to add specific tests I deemed essential to the evaluation throughout. Our patient is a 41 year old male with a referring diagnosis of neck pain and RUE weakness. The patient reports he developed neck pain on 1/11/14 while working out at the gym. It then began to get worse and progressed to RUE pain and weakness. The patient had sought out multiple physician specialities for treatment in the following 2 months. The patient was then referred to physical therapy as a last-ditch effort before surgery. The patient presented on the day of evaluation with constant pain, numbness, and tingling beginning at his R shoulder and traveling down to the elbow. The neck was feeling slightly better that day per patient report. Pain was currently rated 6/10, 3/10 at its best, and 9/10 at its worst according to the VAS. His pain is increased by standing, running, walking, and driving. It is decreased when laying on his side and with his head fully flexed and supported. Patient also reports he has a headache, but denies any TMJ pain or clicking. Patient denies any significant changes in weight over last 6 months, S&S of cauda equina syndrome, night pain, nausea, vomiting. An MRI showed C6-7 lateral disc protrusion. The patient had had an injection in his neck that helped some with neck pain (so did Arnica gel), but has not helped besides that. Patient works from home on a computer, but also has to do lots of flying and driving for his job - several tasks with prolonged sitting. His Neck Disability Index is 38%. Examination: Neuromuscular Screen: -Dermatomes: cervical intact bilat throughout -Reflexes: C5 2+ bilat, C7 2+ on L and 1+ on R Posture: patient sits with FHP and downwardly rotated scapulae (R>L) Cervical ROM: Flexion DN, Extension DN, Rotation DN bilat, Sidebend FN to L and DN to R Shoulder ROM: WNL bilat Shoulder Strength: Abduction, IR, ER all 5/5 bilat Elbow Strength: Flexion 5/5 bilat, Extension 5/5 on L and 4/5 on R Wrist Strength: Flexion 5/5 bilat, Extension 5/5 on L and 4+/5 on R Scapular Strength: Rhomboids 4+/5 on L and 3+/5 on R, Mid Trap 4+/5 on L and 3+/5 on R, Low Trap 3+/5 on L and 3/5 on R, Serratus Anterior 5/5 on L and 4-/5 on R. Segmental Mobility: C1-0 lateral flexion FN bilat, C1-2 rotation DN bilat, Flexion-Rotation test L limited more than R, C4-7 sideglides to L hypomobile compared to R. Special Tests: (-) Transverse Ligament Test, (-) Alar Ligament Test, (-) VBI Test, (+) Distraction Test, (-) Compression Test, DNF Endurance Test 9 seconds (norm=39 seconds for male). Diagnosis: As you may have guessed already from the subjective and examination findings, the patient is suffering from signs and symptoms of cervical radiculopathy. The combination of forward head posture during prolonged sitting/standing for work with imaging findings, reports of neck/upper extremity pain and neural symptoms and upper extremity weakness increases our desire to confirm the suspicion of cervical radiculopathy. Had I performed the examination, I would have preferred adding the Median Nerve ULNT and Spurling's Test to utilize the Cervical Radiculopathy cluster. Something we must also consider is why the patient developed the pathology. The initiation of disc herniation is often due to some form of hypermobility, whether it be traumatic or repetitive stress. With lack of a specific mechanism of injury, it can be assumed that a repetitive stress is the likely culprit. Now why did the repetitive stress occur? We have already identified a pathological posture that the patient was consistently in, but we must remember the patient also showed hypomobility in the upper cervical spine (C1-2 rotation). When the patient performed standing cervical rotation, he was only minimally dysfunctional, however, during the C1-2 rotation breakout pattern, there were noted severe limitations in mobility. This suggests that the patient may have become hypermobile inferiorly (where the disc herniated) as a result of the superior hypomobility. While this is just a hypothesis, it is something that must be considered during our treatment plan. Treatment: Evaluation Day: -Manual Therapy: Grade V manipulation to T6. -Therapeutic Ex: This was the makeup of the patient's HEP. supine chin tuck 5sec x10, supine on half foam roll with BUE horiz. add/abd and reciprocal flex/ext 5sec x10 each, standing wall shoulder shrugs 10sec x10. Samples of select exercises will be shown below. -Mechanical Cervical Traction: 10 minutes 12# max 30:10 on:off ratio - resulted in a slight improvement in pain
Treatment 2: Neck feels a little better each day. Patient states he thinks the exercises are helping. -Manual Therapy: Grade III mob for AA rotation bilateral followed by contract-relax for AA rotation bilat 6sec x3. Grade V manipulation to T6. -Exercise: supine deep neck flexion (DNF), supine chin tuck with rotation, quad rock back with chin tuck, wall shoulder shrug with lift, standing chin tuck with rotation, prone TY exercises, wall push up plus. DNF added to HEP. -Mechanical Cervical Traction: 15 min 16# max 30:10 on:off ratio.
Treatment 3: Pain is worst with prolonged standing/sitting but more centralized now. Weakness persists. -Manual Therapy: Grade V manipulation bilaterally for AA rotation, grade V manipulation to T6. -Therapeutic Ex: added quadruped alternating arm flexion with chin tuck, prone hands behind head scapular squeeze, body blade in flexion and abduction, serratus punches. -Mechanical Cervical Traction: 15 min 18# max 30:10 on:off ratio.
Day 4: Neck feels better each day and is centralized to one spot in neck. No pain with sitting on airplane any more. Scapular pain occasionally occurs but no longer down the arm. Weakness persists. -Manual Therapy: Grade V manipulation for AA rotation bilaterally, grade V manipulation to T6. Lower cervical spine sideglides normal throughout. -Therapeutic Ex: added quadruped cervical flex/ext eccentric, cervical retraction followed by extension, lateral wall walks using hands with yellow theraband. -Mechanical Cervical Traction: 15 min 20# max 30:10 on:off ratio.
Treatment 5: Pain only when driving for prolonged periods; weakness in RUE persists. -Manual Therapy: Grade V manipulation bilaterally for AA rotation, grade V manipulation to T6. -Therapeutic Ex: added seated cervical extension with hands on ipsilateral shoulders, prone ITY exercises, swiss ball walkouts, standing straight-arm lat pull-downs, quadruped rolling ball side to side. Cervical retractions added to HEP. -Mechanical Cervical Traction: 15 min 22# max 30:10 on:off ratio. Treatment 6: Pain is more localized; strength is improving. Patient states retractions work better and he only has pain when driving. -Manual Therapy: Grade V manipulation for AA rotation bilaterally, grade V manipulation to T6, grade V manipulation to C-T junction (no cavitation), IASTM to bilat suboccipitals/scalenes/upper traps. -Therapeutic Ex: added plank lateral walk-overs. Cervical retraction with upper thoracic extension added to HEP. -Mechanical Cervical Traction: 15 min 22# max 30:10 on:off ratio. Treatment 7: No pain when driving. Working out at gym now. Patient reports he is 95-98% improved. -Manual Therapy: Grade V manipuation bilaterally for AA rotation, grade V manipulation to T6. -Therapeutic Ex: added prone row with ER. -Mechanical Cervical Traction: 15 min 22# max 30:10 on:off ratio. Discussion: As you can see, I took a very multi-modal approach. It is commonly accepted that some form of therapeutic exercise is necessary in the treatment of neck pain. Often that exercise progression focuses around the "core of the neck." This is initially begun with supine chin tucks to develop awareness of activation of the deep neck flexors - longus colli, longus capitus, rectus capitus anterior, rectus capitus lateralis. It is then progressed to a supine deep neck flexion while maintaining the chin tuck. Following that, the same exercise is performed in alternate positions (standing, sitting, etc.). Just like the multifidi need to be trained in low back pain, so do the small cervical extensors. This can be done in quadruped, while maintaining a chin tuck. Movement can be trained by switching between these positions and adding flexion/extension, rotation, sidebend. Manual therapy is an intervention that is commonly used with discal injuries (Boyels et al, 2011). However, some people are under the impression that a herniated disc is a contraindication for manipulation. In the acute stage, it is reasonable to assume that the end range positions for a manipulation can be detrimental to the healing of the irritated tissues. However, that does not mean a manipulation elsewhere may not prove beneficial. There has been significant research performed on the benefit of a thoracic manipulation to alleviate neck and shoulder pain (Cross et al, 2011; Masaracchio et al, 2013). We discussed some of the reasoning behind this in an earlier post. However, what about a cervical manipulation. While it is controversial, there have been studies showing the benefit of a cervical manipulation being more successful for neck pain compared to thoracic (Puentedura et al, 2011). An obvious application of this is to free up the hypomobile segment, so that the hypermobile and injured segment no longer has to compensate. This can be done with a cervical manipulation (as done to free up the restricted C1-2 in this patient). While this may be off topic for this particular case, I would like to discuss the need to manipulate the level of the herniated disc. A healthy set of spinal segments rotates around a point in the disc that disperses stress equally throughout (general interpretation). If a facet becomes "locked," that focal point shifts to one side, causing increased stress on parts of the disc - leading to possible herniation. While you still would not want to manipulate that segment in the acute stage, once the patient enters the subacute stage, it may be necessary to manipulate the joint in order to restore normal arthrokinematics, shifting the focal point of rotation into the proper position. As many of you may have realized by now, I am not often an advocate of using modalities. However, when there is sufficient evidence to show the benefit of a specific modality for a pathology, I don't hesitate to trial incorporating it into my plan of care (I may also trial it if the patient shows any biopsychosocial implications that it would help them). There have been numerous studies to show how the addition of cervical traction to manual therapy and therapeutic exercise can improve outcomes (Fritz et al, 2014; Jellad et al, 2009). This patient responded extremely well to the multi-modal approach. Whether it was just the accumulative effects of all the components that led to the 95-98% improvement on that last treatment session or the addition of IASTM in the previous treatment session, I cannot say (I decided to trial it after viewing several videos on the OMPT Channel of The Manual Therapist). As I have written before, initially I was only using IASTM to treat neural symptoms of my patients, with good success. After watching several videos on the OMPT channel, I decided I would try to incorporate it on other patients for different reasons. So far I have found it very successful for treating neck and foot/ankle pain in general when combined with my other treatments. It's definitely something I look forward to developing patterns for patient application. -Chris References:
Boyles R1, Toy P, Mellon J Jr, Hayes M, Hammer B. (2011). Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. J Man Manip Ther. 2011 Aug;19(3):135-42. Cross K, Kuenze C, Grindstaff T, Hertel J. (2011). Thoracic Spine Thrust Manipulation Improves Pain, Range of Motion, and Self-Reported Function in Patients with Mechanical Neck Pain: A Systematic Review. J Orthop Sports Phys Ther. 2011; 41(9):633-642. Fritz JM1, Thackeray A, Brennan GP, Childs JD. (2014). Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial. J Orthop Sports Phys Ther. 2014 Feb;44(2):45-57. Jellad A1, Ben Salah Z, Boudokhane S, Migaou H, Bahri I, Rejeb N. (2009). The value of intermittent cervical traction in recent cervical radiculopathy. Ann Phys Rehabil Med. 2009 Nov;52(9):638-52. Masaracchio M, Cleland J, Hellman M, Hagins M. (2013). Short-Term Combined Effects of Thoracic Spine Thrust Manipulation and Cervical Spine Nonthrust Manipulation in Individuals With Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop. Sports Phys. Ther. 2013 March;43(3):118-127. Puentedura E, Landers M, Cleland J, Mintken P, Huijbregts P, Fernandez-De-Las-Penas C. (2011). Thoracic Spine Thrust Manipulation Versus Cervical Spine Thrust Manipulation in Patients with Acute Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys. Ther. 2011 April;41(4): 208-220.
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