1. July 1, 2012 at 1:10 AM

    Philip Paul Tygiel PT, MTC said:

    I would certainly agree that based on the history and physical examination, lack of red flags and normal neuro findings, a trial of getting this patient moving with manual therapy and exercise is certainly in order.

    We should keep in mind that at least at this point, and probably even after the patient has fully recovered, we can only speculate as to what pathological condition is occuring. That speculation will be based more on our own biases than on any actually known facts. The people who strongly believe that disc derangement is a major cause of such problems will suspect disc derangement. The facet people will suspect facet. The postural stress and muscle imbalance people will suspect those, etc. There are no definative tests, including imaging of all sorts, that will prove any of them right or wrong. Another thing that we should keep in mind is that while it is obvious that he has a kyphotic curve in his lower cervical spine, we can not be sure that this is new or even abnormal for him. That might be his normal curve and might still be present after he is pain free. We did not know him before he showed up with complaints. What I think we can all agree on is that we have to get this guy out of pain and moving better. I would aim my first day treatment to accomplish four things:
    1. Relax the patient emotionally and physiologically.
    2. Modulate the pain.
    3. Restore more normal mobility and posture.
    4. Design an exercise program to maintain mobility and posture gains.

    Relaxing the patient and modulating the pain makes mobilization a lot easier. No one has talked about the use of modalities and I know they are very much not in vogue in some elite therapuetic circles right now as studies with strong “evidence of efficasy” are lacking(which might tell us more about the studies than they do about the modalities. Studies showing they are ineffective are also lacking). I also noticed that this patient was given a muscle relaxant but not an anti-inflamatory. I would prefer the patint use an NSAID and would recommend that.

    In any case following the examination I would have the patient lie on hotpacks for 20 minutes just to get him more comfortable and relaxed (after the first 24-48 hours of onset I prefer heat prior to mobilization rather than ice). Following that I would use some pain modulating modality such as a combination of ultrasound and e-stim to at least temporarily modulate the pain.

    Immediately following that I would proceed with manual therapy techniques. The choice of technique will ussually start with those techniques the practitioner is most comfortable and has the most success with. There is nothing wrong with that despite some calls for eliminating varient treatments. My preference is to start with the patient seated with the weight of the head pulling on the neck and the weight of the arms pulling on the shoulders. If the patient cannot tolerate that, which very rarely happens, I might start with the patient suppine.

    From here the decisions on directions of movement, amount of force, whether to apply traction or not, can only be made moment by moment based on the patients response. I find that, even with the most acute patients, working in the pain free range I can usually find some motions that are freer than others and that relieve some of the pain, fear and guarding. With that done you can also often then extend the pain free range in the directions that were most restricted. Trying to push past the painful points is usually counterproductive and should be avoided.

    If I am successful in modulating the pain and finding and/or increasing the pain free range, the patient is sent home with instructions to exercise in the pain free range TID. The exercises I ordinarily prefer are flexion, side bending and rotation starting from a position of axial extension to engage the deep neck flexors. The exercises are performed in sitting and may be preceeded by moist heat.

    If I am not successful in modulating the pain and/or incresing motion I would send the patient home with instructions to use some moist heat, NSAIDs and relax and then recheck him the next day. Sometimes in cases like this time settles things down and further assessment and treatment cna be accomplished.

    The patient would of course be continually monitored for any advancing neurologicla deficit or other increasing symptoms.


    • July 2, 2012 at 7:53 PM

      Carol Keenan PT DPT said:

      Well put!

  2. June 28, 2012 at 10:08 PM

    Chip Larson, PT, Cert MDT said:

    I too suspect cervical derangement and given the deformity, central/symmetrical pain and obstruction to extension I would proceed cautiously, guiding the lower c-spine into mid-range lower cervical extension (retraction) while supine. I would start supine to minimize compression and to allow soft tissues a chance to relax. I agree with starting with pillow/towel support and gradually removing them based on mechanical signs and symptoms at that given time. My focus would be on gradually re-introducing extension to the lower c-spine and progressing forces / ROM as indicated by mechanical signs and symptoms. I don’t suspect dysfunction as it is an acute case with no prior history and normal cervical AROM being very recent. Great discussion everyone!

  3. June 28, 2012 at 4:03 AM

    Jeanette Krogstad, PT said:

    I agree with the consensus of a derangement dysfunction in this man’s C/S, but also note left upper C/S dysfunction (?acute facet) as seen in the segmental loss of motion into left rotation and right lateral flexion as compared to the contralateral motions. Diffuse muscle guarding can account for some of his ROM loss.

    Before treating, I would likely continue my assessment with gentle palpation in supine to assess for specific levels of guarding and also assess the effect of gentle manual cervical traction as an approach to restore proper neck posture.

    Manual therapy is a broad term, but my simple answer is yes, it has a place in this man’s treatment plan. Gentle cervical traction and gentle soft tissue mobilization would be effective in providing pain relief and improving mobility initially. As his level of inflammation reduces and you are more able to assess the specific loss of mobility, graded localized functional mobilizations or joint mobilizations may be effective in restoring intervertebral mobility. I would follow with pain-free physiologic ROM and neuromuscular re-education in supine before sitting him up to correct posture as tolerated. Obviously, so much depends on how the patient responds to the initial approach.


    • June 29, 2012 at 7:13 PM

      Chris Chase, PT said:

      Jeanette, I observed severe loss of motion in both rotation and sidebending as demonstrated in the pictures, and while maybe not 100% symmetrical loss was noted; with only central pain would you still suspect the facet to be a likely cause of pain. Thanks for your comments.

      Chris

  4. June 27, 2012 at 6:42 PM

    Edward Orloff, PT, DPT, CSCS, Cert. MDT said:

    This is an acute deformity. This is visible obvious, the onset was with the symptoms, change of position affects symptoms and the patient can not correct his position. The motion loss is symmetrical and pain is central indicating that you would likely not consider lateral motions. At this time, I would trial very gradual retractions in sitting to see effect of repeated motions. Sitting procedures would be more functional. However, if this was not tolerated or symptoms remained worsened as a result of sitting retractions I would proceed to supine. While supported with enough pillows to accommodate the deformity I would attempt repeated retractions. If this maneuver increased the symptoms but did not remain worse or improved symptoms, I would send this patient away for 24 hours with this intervention. 10-15x each hour and postural correction as able.

    If symptoms were increased and remained worse, I might trial sustained positioning with gradual progression into extension. If a positive response send patient home with sustained positions aimed at restoration of extension. 5-10 min each hour and postural correction as able

    If sustained increased and remained worsened I might trial manual traction with retraction. If a positive response send patient home hopefully with help from a partner on the technique. 10-15x each hour and postural correction as able.

    Finally if all else fails perhaps some traction in a flexed position (may be helpful for especially stubborn derangements).

    Or just give it some more time.


    • June 27, 2012 at 7:53 PM

      Carol Keenan PT DPT said:

      excellent presentation and I agree but may introduce manual traction a bit earlier. Suggest cervical roll/proper pillowage for sleep.


    • June 28, 2012 at 5:58 PM

      Linnet C. Kazemi, PT, DPT, Cert MDT said:

      I have to say, as it is an acute cervical deformity, I think I would proceed straight to supine with an accomodation of the deformity with pillows. I would work slowly into the retraction position removing the pillows as I was able.

  5. June 26, 2012 at 8:48 PM

    Gerard Breuker, PT, MSc, OCS said:

    Before initiating treatment, I would proceed with subcranial stability testing. When negative, continue with manual assessment of C0-C1-C1-C2 mobility and segmental mobility of the rest of cervical and upper thoracic spine.The patient is displaying symmetrical loss of upper cervical mobility, which could be indicative of a capsular pattern. Since it was mentioned that the patient “was stuck in protrusion” and rotation and lateral flexion are significantly and equally limited, it is very reasonable to expect significant OA and C1-C2 mobility loss. Apply manual techniques to restore upper cervical movement. Next, focus on restoring flexion mobility in the lower cervical spine, using appropriate manual techniques. Judging by the patient’s Thoracic posture, Thoracic mobility is most likely insufficient and needs intervention.
    So, yes, there is absolutely a place and need for (skilled) manual assessment and techniques here.


    • June 27, 2012 at 11:00 PM

      Chris Chase, PT said:

      Question to consider. Could the lower cervical kyphotic deformity be limiting his cervical rotation? In other words, could he have normal upper cervical mobility but still present with the major loss of movements which come primarily from upper segments? I am also curios if the statement “Next, focus on restoring flexion mobility in the lower cervical spine, using appropriate manual techniques.” is supposed to read extension or if you would first focus on flexion for this presentation? If so, why flexion when the patient is fixed in a forward flexed position?


      • June 27, 2012 at 11:44 PM

        Gerard Breuker, PT, MSc, OCS said:

        Most defenitely. I agree. In a cervical protrusion position, cervical rotation and sidebending are most likely limited. The lower cervical spine does not display any significant amount of flexion, so that would be my focus. “Flexion: Major loss with no movement coming from his lower cervical spine” was also your conclusion, I believe.
        Wouldn’t you agree that, with this tremendous amount of mm guarding, there is a need for supine passive intervetertebral motion assessment before moving forward? The upper cervical segments e.g. can be assessed and cleared in a matter of moments.

  6. June 26, 2012 at 3:02 PM

    theartofsciences said:

    Provided I could not have an XRAY for this patient before the patient was referred to the Physiotherapy department, I refer the patient to the HEAD of the Physiotherapy department and I GO ON HOLIDAYS for a whole month.
    SERIOUSLY.

    Always,

    Paule Morbois
    Meise – Belgium


    • June 27, 2012 at 10:55 PM

      Chris Chase, PT said:

      At this point, we understand your concerns and request and desire for imaging on this patient, but let’s move forward as we are going to proceed with caution and monitor symptoms and agree to commence treatment for the sake of the intent of this blog. Which is to provide an educational experience for treating a patient with a very particular presentation.

      Chris

  7. June 26, 2012 at 12:28 AM

    Larry Davis, PT said:

    I would begin with the patient supine, supported on a pillow or 2 as needed and assess if gentle manual traction provides any relief. If so, then I would gently assist the patient with movement during the traction as tolerated, constantly assessing for increased pain and looking for improvement in the pain-free range of motion. I might also apply soft tissue massage in supine as tolerated. As symptoms decrease in the supine position, I would have the patient perform gentle retraction as tolerated, again looking for improvement in symptoms and working toward extension beyond neutral (with his head over the end of the table) as able always supporting his head with my hands to reassure him. I would do the same for side bending and rotation bilaterally, looking for nearly normal motion in supine before progressing to AROM in upright posture.


    • June 27, 2012 at 11:04 PM

      Chris Chase, PT said:

      Larry, I am curious why you would address lateral movements before returning upright. One school of thought is to avoid lateral movements with this presentation for fear of creating a torticollis. Could you explain why you would add rotation and sidebend movements first?

      Thanks

      Chris


      • Larry Davis, PT said:

        June 28, 2012 at 12:19 AM

        My thought in addressing these movements in supine before returning to upright posture is to minimize compressive forces on the c spine as the movements are assessed and hopefully restored. I would proceed with assisted lateral movements cautiously of course, keeping them in the pain-free range of motion while looking for more movement as the muscles begin to relax.