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Treatment of a Cervical Disc Herniation in a Young Male

7/17/2014

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Picture
Today's Case 
Treatment for a 28 year old male who presents to the Harris Health System with a C7 cervical disc herniation. 

Diagnosis of a cervical disc herniation was made based on: 
- +ive C7 Dermatomal and Myotomal testing 
-Specific strength testing of musculature innervated by C7
-Visual inspection/palpation of triceps atrophy and wrist extensors
-Pattern of pain 
-Confirmation with MRI findings

Additional important testing performed:
-Cervical range of motion testing was within normal limits with pain at end-range bilaterally
-Shoulder range of motion was within normal limits. 
-Joint Mobility: Upper cervical mobility assessment was within normal limits; lower cervical mobility opening restrictions were present from C4-C7; 1st rib hypomobility bilaterally; middle and upper thoracic extension restrictions
-Muscle testing was performed using a hand-grip dynamometer. 
     Triceps: L: 33, R: 15.4  
     Middle Trap: L: 23, R: 20 
     Lower Trap: L: 19, R: 16
     Hand Grip Dynamometer (average of 3): L: 95, R: 75                          *Patient is R hand dominant
     DNF (Kendall MMT): 8 seconds

Patient's Goals: Return to weight lifting, playing basketball, and full duty at work as a waiter.

A Look at the Literature
When looking over different interventions, management of individuals with cervical disc herniations is lacking in the literature. Furthermore, there has been even less published regarding the usage of both manual therapy and the cervical unloader (traction) for management of these patients. A 2007 article found that 67% of patients diagnosed with cervical radiculopathy responded positively to thoracic spine thrust manipulation (Cleland 2007). The clinical practice guidelines for neck pain recommend thoracic manipulation (Grade C evidence) for both pain and disability. Regarding traction, the guidelines recommend (Grade B evidence) mechanical intermittent traction be combined with other the use of other interventions (exercise and/or manual) therapy for individuals with neck and arm pain (Childs 2008). 
My Treatment
Based off his initial evaluation, I knew scapular strengthening as well as triceps strengthening were essential components of my treatment. Additionally I wanted to normalize cervical and thoracic joint mobility. Finally, I wanted to incorporate the use of a cervical unloader to optimize the patient's success.

Thus far I have performed 4 treatment sessions on the patient. Each treatment is structured as:
1. Supine Thoracic Manipulation and Cervical Segmental Mobility
2. 10 minutes on the Cervical Unloader + Upper Body Ergometer (progressive resistance)
3. Cervical Unloader while performed progressive resisted Tricep theraband extension (3-4 sets x 10 RM)
4. Scapular strengthening exercises (standing theraband T's, prone T's, prone Y's (3 sets x 15 reps)
5. Postural Education

His reassessment results have been positive. Joint mobility has normalized, static sitting posture has improved, muscle strength has improved, and pain (not stated above) has significantly decreased. So far his outcome measures (NDI and FOTO) have not met the MCID.  

Specific muscle strength as reassessment (using dynamometry):
     Triceps: L: 34, R: 19
     Middle Trap: L: 34, R: 29  
     Hand Grip Dynamometer (average of 3): L: 95, R: 82                          *Patient is R hand dominant
     
At reassessment he reported 65% improved and has returned to shooting basketball, lifting, and working full duty.   
Picture
Conclusion
I am continuing to treat this gentleman as of today. He reports 90% improvement. I have progressed to only using the cervical unloader during the warm-up and decreased manual therapy interventions. Final treatments are addressing plyometric aspects of sport and maximizing strength. From this single case experience I have found that using a multi-modal approach of manual therapy, cervical unloader with therapeutic exercise, and standard exercise has been effective in treating a young male with a C7 disc herniation.  

-Jim 

References:

Cleland JA, Fritz JM, Whitman JM, Heath R. Predictors of short-term outcome in people with a clinical diagnosis of cervical radiculopathy. Phys Ther 2007;87:1619–32. 

Childs J, et al. Neck Pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the APTA. JOSPT. 2008: Sep (9): A1-A30.  
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  • Home
    • Newsletter
    • About
  • Featured Articles
    • Sports Physical Therapy >
      • Functional Return to Sport Testing
    • Residency Corner >
      • Research Articles
    • Cervical Course
    • Lumbar Course
  • Special Tests
    • Cervical Spine >
      • Alar Ligament Test
      • Bakody's Sign
      • Cervical Distraction Test
      • Cervical Rotation Lateral Flexion Test
      • Craniocervical Flexion Test (CCFT)
      • Deep Neck Flexor Endurance Test
      • Posterior-Anterior Segmental Mobility
      • Segmental Mobility
      • Sharp-Purser Test
      • Spurling's Maneuver
      • Transverse Ligament Test
      • ULNT - Median
      • ULNT - Radial
      • ULNT - Ulnar
      • Vertebral Artery Test
    • Thoracic Spine >
      • Adam's Forward Bend Test
      • Passive Neck Flexion Test
      • Thoracic Compression Test
      • Thoracic Distraction Test
      • Thoracic Foraminal Closure Test
    • Lumbar Spine/Sacroiliac Joint >
      • Active Sit-Up Test
      • Alternate Gillet Test
      • Crossed Straight Let Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
      • Active Compression Test
      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
        • Adson's Test
        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
      • Biceps Squeeze Test
      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
      • Allen's Test
      • Carpal Compression Test
      • Finkelstein Test
      • Phalen's Test
      • Reverse Phalen's Test
    • Hip >
      • Craig's Test
      • Dial Test
      • FABER Test
      • FAIR Test
      • Fitzgerald's Test
      • Hip Quadrant Test
      • Hop Test
      • Labral Anterior Impingement Test
      • Labral Posterior Impingement Test
      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
      • Anterior Drawer Test
      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
      • Anterior Drawer
      • Calf Squeeze Test
      • External Rotation Test
      • Fracture Screening Tests
      • Impingement Sign
      • Navicular Drop Test
      • Squeeze Test
      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test
  • Insider Access
  • HEP
    • Neck and Shoulder >
      • Supine Chin Tuck
      • Supine DNF with Towel Assist
      • Supine DNF
      • Standing Chin Tuck Against Wall
      • Standing Chin Tuck Against Wall with Scaption
      • Seated Cervical Retraction Repeated
      • Seated Cervical Retraction with Extension Repeated
      • Seated Cervical Retraction with Sidebend Repeated
      • Seated Cervical Retraction with Rotation Repeated
      • Standing Wall Shrugs at 90 Degrees Flex
      • Seated Thoracic Whips
      • Standing Ballistic Shoulder Extensions
      • Standing Repeated Shoulder Extension with Squat
      • Standing Repetead Shoulder Horiz. Abd. with Ext. CKC
      • Seated with Arms on Pillows Cervical AROM (Flex/Ext/Rot/SB)
      • Seated with Arms on Pillows Shrugs
      • Seated with Arms on Pillows Shrug with Scapular Retraction
      • Supine Shoulder IR with GH Centralization
      • Supine Shoulder ER with GH Centralization
      • Holding Dumbbell at 180 Degrees Flexion for Time
      • Cat Camel
      • Prone T's
      • Prone Y's
      • Quad Chin Tuck w/ Shoulder Flexion
    • Low Back >
      • Supine TA Isometric
      • Standing TA Isometric Agains Wall with Squat
      • Supine BKFO
      • Quad Rock Back
      • Standing Hip Hinge
      • Sit to Stand with Hip Hinge
      • Repeated Lumbar Sideglides
      • Repeated Standing Lumbar Extension
      • Repeated Standing Lumbar Flexion
      • Repeated Prone Press-Ups
      • Repeated Supine DKC
      • Slump Sciatic Nerve Glides
      • Birddog Progression
    • Hip and Knee >
      • Clamshells with Progressions
      • Fire Hydrants with Progressions
      • Donkey Kicks
      • Bridge Variations
      • Repeated Hip Flexion
      • Squats
      • Seated Repeated Knee Extensions
      • CKC Seated Repeated Knee Extensions
      • Heel Slides
      • CKC DF with Tibial IR
    • Foot and Ankle >
      • Calf Raises
      • Calf Raises with Soccer Ball Between Medial Malleoli
      • Towel Scrunches with Foot in PF
      • Toe Flexion Using T-Band with Foot in PF
      • PF with Toes Flexed Using T-Band
      • DF with Toes Flexed Using T-Band
      • Forefoot Adduction
      • Gastroc Stretch
      • Repeated PF
    • Examination Templates
  • Store
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