Treatment of a Cervical Disc Herniation in a Young Male

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.

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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.   

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 

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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.