1. June 25, 2012 at 11:12 PM

    kübra said:

    ı want xray.Because the pain went on over two days and ı should learn whether the patient has subluxation of vertebra.There is a possibility of subluxation.ıf there isnt,ı will do my assesment.ı asses his limit of active and passive neck motion,his muscles spazm and his postüre.and then ı treat him using this options:tens,connective tissue massage,neck manipulation,stretching,active neck motion(this motion cannot cause pain.ı increase motion’s limit in the progress).ı educate the patient about how he sit and walk straight.ı educate the patient about his ilness.ıf he go on his wrong postüre,acut tortikollis can repeat and his job which is climber trigger tortikollis. (ı hope you get my english.thanks everyone!)

  2. June 22, 2012 at 8:49 PM

    theartofsciences said:

    It is my understanding that even in the most remote areas in the world, maybe not in area which are poverty striken, there are emergency services where this very patient would have entered.

    In the initial description of the case. there is mention of extreme pain to change of position. The majority of Doctors would have referred this patient to an XRAY from the emergency room and therefore the debate would have started with the knowledge and result of the XRAY results.

    The time lapse between a potential Xray and begining of treatment is difficult to admit as potential reasoning in begining Physiotherapy treatment.
    In any case I would not.

    The need for litterature to back up reasoning in this post is taking as much time as the time it would take to have an XRAY done. Where is the logic?
    By the time we are all finished debating, the Physiotherapist in charge of this patient will probably well advanced or finished the patient treatment.

    Paule Morbois
    Meise – Belgium

  3. June 22, 2012 at 4:46 PM

    Chris Chase, PT said:

    Wow, great to see some passionate responses. However, let’s remember we are all here to learn, and not by disparaging anyone for their viewpoint. We come from different experiences, backgrounds and training – that’s why these forums are so great to share and learn from different perspectives! Let’s please respect that.

    Just a few comments before the examination is posted next week.

    The theory that this could be inflammatory in nature and needs to be left alone was mentioned. There is evidence that acute torticollis and cervical deformities will spontaneously recover a majority of the time if left alone, however if we have the ability to help this patient at this moment, shouldn’t we try. Left untreated this could develop into a lateral toticollis or worsen into a condition that needs to be treated surgically. If the inflammatory response is dominant than, there will be no position, movement or activity and alleviates his pain. The patient was taking NSAID’s but couldn’t tell if they were helping. Acute pain is often a mix of mechanical and chemical responses and I believe only if there is no sign of mechanical response, should we leave a condition like this alone. It will become clear that this condition did respond mechanically.

    As for the ongoing suggestion that treatment should be delayed until an x-ray is taken, I offer you this to think about. In some areas it takes days to authorize or schedule tests (especially when certain insurance companies can get involved) and delaying treatment in this instance could allow the condition to worsen and the patient to suffer from the pain unnecessarily. I was glad to see the article mentioned recently that mentions health care costs rise rapidly once imaging is ordered. Tim Flynn presented information at the American Academy of Orthopedic Manual Physical Therapists (AAOMPT) conference this past fall that details the increase in surgery, overall cost increases, and fear that can be created when imaging is ordered. I always put my patient’s safety first and at the first sign of red flag pathology I would stop treatment. I think PT’s in general should use their clinical reasoning when deciding when to treat or not treat, and routinely requiring special tests that can be costly, increase fear and delay treatment can be a deterrent in providing quality care.

    Lastly, there are a number of responses that indicate what the McKenzie response to treating this condition would be. I am interested to hear from other schools of thought, what your management strategies would look like for this presentation.

    Thanks and I hope everyone enjoys their weekend.

    Chris Chase, PT

    • mk said:

      June 23, 2012 at 3:59 AM

      Mr. Chase, thank you for the presentation of this case. But the varied responses suggest a bigger issue within the profession. Your comment ‘We come from different experiences, backgrounds and training’ is well taken, however, shouldn’t there be a standard of care based on evidence based practice. With the APTA pushing for therapists to be doctors of physical therapy practicing with autonomy, i would hope so. Medical doctors (the majority)follow these standards everyday while treating hypertension, diabetes, hyperlipidemia, etc. If we as a profession want to be treated like ‘doctors’ shouldn’t we have an approach that is based on evidence based practice (i am not talking cookbook care). I realize that this is your case presentation and you are being a statesman. You have responses on here from MDT, to assessing leg length, pelvic asymmetry, doing core work, and not even touching the patient until an xray is done. All I am saying is that if we as a profession want to be treated with more respect by the community and other medical professionals, a level of care reflecting our doctoral level of education should exist. By the responses given here I question it (core work???? really???).

    • June 26, 2012 at 6:11 PM

      Ziadee Cambier, PT, DPT said:

      As a PT fairly new to the profession (just under three years), I am not familiar with all the schools of thought. I am trained in Maitland based manual therapy, which sounds similar to MDT in its focus on signs, symptoms, and response to mechanical stimulus. I wonder if anyone is familiar with both and would be willing to comment on similarity/differences for my edification?

      My approach would be to proceed with a modified mechanical exam due to the severity of the patient’s case (no red flags as many have mentioned). Where I would normally look to reproduce a patient’s pain with my exam, in this case I want to stop at or prior to first signs of pain. My goal would be to look for positions, passive or active motions, and gentle mobilizations that decrease the pain and use the best of those as treatment on day one. Direction of force would be 100% dependent on pt response to the exam.

      Ziadee Cambier, PT, DPT

  4. June 22, 2012 at 7:11 AM

    Ashley D. said:

    I think it is safe to proceed with a mechanical assessment given no red flags or traumatic injury.
    Provisional classification: cervical derangement given the ROM loss and acute onset and MOI
    Loading strategy: cervical derangments typically respond best to loaded movements (sitting) but given the high levels of pain and acute pain, he may benefit from unloaded movements in supine.
    I would accomodate the deformity in supine using several layers of thin pillows or towels. The goal is to slowly remove layers and move the patient into a more neutral position and eventually retraction. Only move as quickly as symptoms dictate, meaning no peripheralization of symptoms or worsening of symptoms. Its important to test in the saggital plane before considering “stretches” or movements laterally. Note that this process could take up to 30-45 min in order for the derangement or obstruction into extension/retraction to change. Especially given that he may be in a chemical state/inflammation, which can muddy the water a bit with regards to directional preference. Be patient, move slowly and accomodate the deformity so that the patient is not guarded to movement.

  5. June 22, 2012 at 4:47 AM

    Lee Chaffee said:

    We do have the Canadian C-Spine Rule to assist us with this unusual case (Stiell, IG, et al.JAMA2001; 286: 1841-1848) particularly regarding the possible need for radiology before proceeding with other interventions:
    1. Any High-Risk Factor That Mandates Radiography? NO, so continue to…
    2. Any Low-Risk Factor That Allows Safe Assessment of Range of Motion?
    A few concerns here:
    a. sitting position in ED
    b. delayed onset of neck pain
    c. absence of midline C-Spine tenderness
    3. Able to Actively Rotate Neck?
    45* Left and Right—————->Unable, then proceed to Radiography.

    Perhaps the prudent course, despite the many expert and competent opinions expressed thusfar, and the presumed desire of the client, especially in the unlikely event that the client should suffer an untoward outcome, take a dislike to the intervening therapist, or simply passionately disagree with available parking; perhaps, we should take a closer look at what some of our guidelines and literature provide and not be too surprised if, heaven forfend, we are summoned to court and face disagreeing experts and disagreeable findings.OOPS!

    • June 22, 2012 at 8:15 PM

      theartofsciences said:


      where is the DELAYED ALREADY WRITTEN Canadian litterature when needed in case of Physiotherapeutic debate?
      The problem with all these debates is the delayed reaction (no offense meant) of the major intervenants in health, in this case the XRAY technician referral, only because 99% of patients are of fairly similar routine. There is this 1% unknown aetiology that could happen.

      I understand, Mr Chase has the answer to this case and is therefore in no hurry of either giving too much informations to those of us who took the time in responding to these case study.
      I surely hope you have a good excuse to reach this forum with this Canadian litterature on almost last posting. Busy at work or at the library?

      However, more seriously, if there was no antecedent in the litterature, would you have commented?
      We are, in healthcare, lost in the sea of litterature and comments based more on what will develop professional confidence and in which there is very little consideration for the 1% not so routine case.

      Anyway, thank you for your research in the litterature.

      Paule Morbois
      Meise Belgium

    • June 23, 2012 at 7:04 PM

      Jim said:

      Isnt the canadian c spine rule used for and validated for trauma pts only? So I am not sure if we should even use it for pts that doesn’t have any history of trauma.

      • June 24, 2012 at 6:44 PM

        theartofsciences said:

        Mr Jim,
        I know this comment is not address to me and I also know that I have never practiced Physiotherapy in USA or Canada. However, I would like to write this in response to your last comment.
        Physiotherapy is neither practicing law or making a movie with the patients referred to me for treatment.
        Lack of confidence in treating patients implies trying and find an antecedent or rule, such as would lawyers to “win their case”. Healthcare professionels practice the care of health. Therefore, countries develop their own priorities and set of “rules in practice” which might differ depending of where the practice is done.

        Of course I would not use an neurodevelopmental assessment on an orthoepaedic patient or vice versa. Yet I would, in my own assessment include the relevant commentaries and notes to the case present. Yet, in my assessment there is ALWAYS a paragraph for RXAY, MRI, CT SCAN… result which is MOST relevant to the case.

        You wrote the “canadian C spine rule” for trauma only. However, your decision as a Physiotherapist in charge of this patient, will not only reflect your ability to assess and adapt the appropriate method of assessment treatment of this patient and also your understanding of prioritising, litterature and routine protocole over a well understood, neuromuscular history based case (I will leave aside the potential for oncological problem).

        When one element as important as an XRAY is missing… what would you do as a physiotherapist? Technically it is the ONLY professional response to answer with every patient referred to you professionally.
        This online case is very artificial and bound to receive interferences from other medias ridiculising healthcare further.

        Healthcare professional OPINIONS based on sound knowledge of causality and treatment are the most important in healthcare, without… the healthcare becomes astray or void of its purpose: “THE BETTERMENT OF PEOPLE’S HEALTH.

        And when my professionel opinions and discussions are tempered with other irrelevant medias to the debates and therefore the betterment of people’s health becomes jeopardised, then I might as well write to the governments and thank them all in turn for having mocked people’s health…



        Paule Morbois
        Meise – Belgium

  6. June 21, 2012 at 11:06 PM

    Mauro said:

    Hello everybody.I think that It’s safe to do a mechanical evaluation ’cause the patient doesn’t have sign or symptoms link to a red flag and I think that It’s important to have more information for the treatment.For the second question,the category maybe an impairment syndrome due to incorrect posture and movement performed without respect the correct axis of movement.In this phase I think that we have to do no aggressive treatment acting on tissues to reduce the spasm and with mobilization of T1 to start to regain movement.

  7. June 21, 2012 at 5:54 PM

    Dvir Chen said:

    I think that since this patient came to the clinic two days after onset of pain the question is “to treat or no to treat”. Since two days is still in the 5-7 days of the initial inflammatory phase should we intervene in this case.
    For Chris : Was the patient taking NSAID’s? What was the effect if he did?
    Should we perform a mechanical evaluation when it is clear form the history that the patient is still within the time frame of an acute inflammatory process?

  8. June 21, 2012 at 12:48 PM

    Paul E. Underwood, PT, CSCS, Cert MDT said:

    Good morning Marilyn!
    I’m an MDT cert PT in Mooresville.
    I wil reply to this case study, but would like to also use this as an opportunity to educate some of my colleagues outside MDT.
    May I share this exercise?
    Many thanks!

    • June 21, 2012 at 10:15 PM

      Marilyn Pink, PT, MBA, Ph.D. said:

      GREAT IDEA, Paul!! Yes, I think non-MDT folks could learn a lot about MDT by following this case. Chris has lots of good info in store of the participants. Please DO share this with your colleges. There will be free articles coming too that might help them understand more about MDT. The whole purpose of this is to LEARN and EXPAND. Some folks may choose to post a reply, and many folks simply read what others have written and learn that way.

      So, share away!!


  9. June 21, 2012 at 7:54 AM

    ws said:

    1. I believe it’s safe to go ahead with mechanical assessment.
    2. I would suspect derangement from information given.
    3. Gentle/to pt tolerance. Let pt response guide assessment.
    4. I would start with pt’s own force (self-generated) to tolerance in loaded position (sitting with corrected posture) since necks usually respond well when loaded.

  10. June 21, 2012 at 4:44 AM

    joe said:

    in my experience, upper thoracic kyphosis spells hypomobility with a resulting segmental hypermobility in the cervical spine. cervical spine functional eval. & Rx should never forsake the upper thoracic region (T1-3).

    • June 21, 2012 at 5:05 PM

      theartofsciences said:

      Yes, this much is true the hypomobility of the thoracic level provoke hypermobility as compensatory mean of the cervical region. however, in the presentation, the patient is said to be a rock climber, so it is unlikely that the patient (34 years old) might have a thoracic kyphosis (mobile or fixed).

      This reminds me of the movie recently out in the cinema with a rock climber.

      Paule Morbois

      • June 26, 2012 at 5:51 PM

        Ziadee Cambier, PT, DPT said:

        I don’t agree that we can assume spinal health based on age and activity level. Although I rarely work with young people, I’ve seen at least two active patients under 40 with significant thoracic kyphosis.
        Ziadee Cambier, PT, DPT

      • June 26, 2012 at 8:35 PM

        theartofsciences said:

        mr Cambier,

        Spinal health is mostly defined at 99% by the age and activity level, the 1% is for all genes defects which temper in utero development and which later develop spinal defect. THIS MUCH IS TRUE provided the patients’ genes are INTACT.

        if you wish to check the litterature, there are countless articles from vitamin D to calcium supplement to defect in generating either, in the average population and more so, surveys which involve developing children until adulthood focusing on their bones development, athletes bones structures, injuries and overuse due to the demand based by their physical activites.

        If you decide to seek into the 1% which has gene defect, then the vertebrae structures and other long bones structures become important to take into consideration, of course.

        The morphology of this patient, however, does not let me think that he suffer frome a inborn genetic defect which could lead to defect to his spinal vertebrae.


        Paule Morbois
        Meise – Belgium

  11. June 21, 2012 at 2:23 AM

    Carol Keenan said:

    Wow! This forum is such a microcosm of why I am really disillusioned with our profession! I agree with the MDT trained therapists that there is some scary stuff on this blog. I would venture to predict that the several therapists that are focusing on the lower chain and pubes will find this to be the cause of 90+% of their musculoskeletal referrals. I truly encourage these therapists to add more tools to their toolboxes. You are truly doing a disservice to your patients. I am currently rehabing a pt s/p lat menisectomy from injury sustained by a like minded PT who was treating her ELBOW injury!

    More specifically to this patient, I would have liked to know more about the actual head posture while sleeping in the car…it could help in the mechanical diagnosis/evaluation. I would definately proceed with a mechanical eval and agree with a probable derangement syndrome classification due to acute onset and loss of ROM/postural deformity. It will likely by extension biased but that is what the eval is for.

    I’d like to get feedback from other therapists on their estimate of MDT trained therapists in outpt practice. I feel that it is far too small and our university programs are not training or sharing the highly successful evidence with those entering the profession. I was personally trained by Robin McKenzie back in 1983 and there is no approach that has come close to successful outcomes and preventing reoccurence than this method. (I also have much training in muscle energy, mobilization/manipulation, etc..) I read an interesting recent interview of McKenzie, and one of his greatest concerns is the watering down of the approach by not MDT trained therapists. I see this with colleagues that think they know this approach but sadly cannot evaluate, treat or educate their patients appropriately.

    • June 21, 2012 at 5:28 AM

      Jim said:

      Preach it 🙂

    • June 21, 2012 at 6:22 AM

      Joel said:

      You got it, gently treat the acute “wry neck” and forget the pelvis! What is going on with the suggestions of treating pelvis in THIS patient?

    • June 21, 2012 at 2:05 PM

      JOHNL said:

      well said.

    • June 21, 2012 at 4:31 PM

      theartofsciences said:

      ms Keenan,

      I only just wrote this in my comment, before touching the neck of this patient, I would insist in having an XRAY. Correctly enough 99% of patients referred to physiotherapists will do well with physiotherapy, there is ALWAYS the 1% patient which is OUT of the norm, out or the rules of cheaper and sameness physiotherapy/medical approach.

      The economy of medical approach and the economy of physiotherapy approach will ALWAYS IGNORE the RULE of safety and appropriate care.

      The pain might be caused by underlying problems either orthopaedics, neurological or oncological. Before a patient with cancer suffers with pain, the patient might feel absolutely well and then the lump (localised cervical kyphosis).
      The cause of the cervical pain might not be either due to the fact that the patient slept in the back of his car.
      Well I may be a trained physiotherapist, yet I can’t see trough the underlying tissues in the cervical region of this patient.
      Do you think this patient have a tethered spinal cord?
      Do you think the patient could have a spinal cyst?
      Do you think the patient could have a neuroma and do you think this could be cancerous?
      Do you think the patient might have tried to hang himself and fell off his cord? No there is no trace of restraint in the neck area.
      Do you think the patient could have a cervical spine micro subluxation?
      Do you think the patient could have a viral infection?

      Yes, correctly I am not trained with the McKenzie technique or trained with Maitland technique, my years of physiotherapy practice have thaught me that having an XRAY and a clear picture of the patient factual symptoms and causes is a must before putting my hands and maybe provoke more damages to this patients which the insurance might not cover anyway.

      Anyway, I may be wrong and this would be a relief for this forum because I would have wasted the time and money of the healthcare department shouting to have an XRAY and your time as an MDT trained therapist.

      I could be right in being confident enough in insisting to have an XRAY and this forum would have wasted my time …

      Paule Morbois

      • June 22, 2012 at 3:01 AM

        Carol Keenan said:

        Thank you for your response, but I don’t believe I address imaging in my response. Except to state that I would proceed with mechanical eval (w/o X-ray). There is some VERY good evidence on the pros and cons of imaging and CPR’s on optimal efficacy (not only $ saving issues). The Journal of Ortho and Sports PT 2012 (?March) had 2 very good articles/studies. I am concerned that you seem to equate your hand as lethal weapons. A conservative mech eval can cause virtually no harm and will very likely help this unfortuante man get out of excruciating pain. I agree with the therapist that responded to your original post- Be Confident. If it takes further research and education, listening to other colleagues (which I give you credit for doing in this forum!)

        You asked me many questions re: did I think it could be…..etc. Infact- NO. I have seem this sort of scenario many times in a 31 yr career(including DPT) and I am confident that I have the skills to really help this man. If he responds in an uncharacteristic way, that is when I would communicate with referring MD and make recc accordingly. Proceed with the eval and make recc if necc. Please remember that imaging has risks, false neg/pos, “red herrings”, etc.

    • June 22, 2012 at 3:46 PM

      theartofsciences said:

      Ms Keenan,

      I am confident in a conservative approach, and that is why I insist so much about the Xray.

      If this particular patient was referred to me, amongst my first question would be: have you had an Xray done of your cervical spine and do you have the Xray with you? So I could have a look at the Xray to actually see what this “cervical lump” is.
      Without being cycnical, I know that the Greek God zeus, equivalent to the roman God Jupiter, delivered his daughter out of his tigh, this would equivocate to a lump where a lump should not be.

      I understand, your confidence in the both theoritical and practical physiotherapy practice, inasmuch as I have confidence in my own theoritical and practical physiotherapy practice.
      What needs to be remembered is that very 1% negligeable unknown aetiology which is rarely encounter by healthcare practitioners (in all areas of practice).
      Quite correctly stated in your initial post Ms Keenan, practioners are confident with what they know because they have been trained adequately. McKenzie or Maitland give you the expert knowledge for this patient.
      Confidence is therefore based on the focus practioner develop in particular area and that is important. Within that confidence, there is over confidence because of the routine which develops.
      This however is not a repproach, it is a fact in all work areas.

      If I set my alarm clock to wake me up every week day at a certain time, I too will be confident that my alarm clock will do exactly that of waking me up.
      Then, there is 1% odd, my alarm clock does not ring and I am left getting up in a hurry rushing to whatever I am supposed to be doing, because I would be late.
      The faltering of my alarm clock tells me not to be 100% confident in routine sameness and to remember and try and alleviate the 1% unexpected.

      My observation as a physiotherapist is still limited by the one crucial element, that of “excrutiating pain” of the patient. and a rock climber, well muscled (the patient can probably carry his own body at the tip of his fingers) who after sleeping in a car wakes up with such cervical lump is not that common and the patient himself has no explanation for it either.
      cervical hernia is not that common either, is it?
      What about cervical bursitis?

      If I remain focused on this particular patient and begin questioning the “broader term” of “systemic disorder”. For this there is no study done and therefore no result. And all the best trained Physiotherapist in the world will do everything they can to remain focused on this patient and yet quite correctly and yet, the “broader term” is ignored. Therefore there is no solution for the “systemic disorder”, which caused the excruciating pain of this patient, never.

      so I keep asking even shouting for the Xray of this patient even if Xrays or other imaging techniques can falter in showing what I would be looking for.


      Paule Morbois

    • June 29, 2012 at 6:43 AM

      Herschel Budlow said:

      I want to agree with the various comments that are critical of the extreme emphasis upon the lower kinetic chain approach. I am certain I am older than the majority of the PTs who contributed their time and energy to this blog. I can distinctly recall the controversy many years ago when the focus was the SI joint for back and lower extremity symptoms. Suddenly, nearly every patient with lumbopelvic and lower extremity radicular complaints “had” to have an SI joint malady of some sort. Depending upon what seminar was the flavor of the month, the descriptive terms used by the examining P.T. alluded to an SI JOINT problem. Think horses when you hear hoofbeats….not zebras. I am very respectful of “today’s” highly educated and throughly trained PTs. However, as a clinician in my 50th year of continuous patient care, I think I have kept as current in my thinking and education to feel confident in my therapeutic approach, while realizing my limitations in certain areas of practice. We all have put a variety of tools in our clinical toolbox, and hopefully realize that those of us with different approaches – that may seem passé to some – still yield good results in experienced hands. I still would not do anything beyond symptomatic therapy for this patient (cold packs+EMS followed by gently applied ice massage and comfort positioning). I would not perform ANY MDT whatsoever without cervical spine X-ray.

  12. June 21, 2012 at 1:15 AM

    Christie said:

    Nice summary, Chris. I agree with your assessment. No need for spinal imaging without trauma or neuro signs. I think an unloaded position with pillows to accommodate the deformity are called for. Gentle retractions into the pillow, progressing to removing pillow. He may require some manual traction.

  13. June 21, 2012 at 1:08 AM

    Donna Galotta said:

    I agree that is it safe to proceed with a mechanical evaluation and that this is a derangement that most likely needs retraction. I would move slowly with this patient watching for responses in ROM and symptoms.
    I also agree that there is no need for imaging at this time as there is no apparent neuro signs, trauma or any other red flags.
    I would start in an unloaded position if tolerated by the patient. I like the idea that Jim had of placing a towel under the head to accommodate for the deformity like one does for a kyphotic deformity of the lumbar spine.

  14. June 21, 2012 at 12:01 AM

    Zach said:

    I would proceed wityh a mechanical evaluation. ROM, tolerance to repeated movements as appropriate to patient tolerance. Xrays would likely be minimally helpful, with no history of trauma. I would proceed with unloaded movements and traction as a less aggressive direction, based on irritability of patient symptoms. I would classify as derangement, as dysfunction would take much longer onset to become that significant. Based on the limited information, I would try traction and proceed to extension for direction of preference, If his position was something more extreme it may alter the direction I would stretch him into to decrease current spasm.

  15. June 20, 2012 at 11:42 PM

    Ben Ness, PT, MS, Cert. MDT said:

    I don’t see anything that would keep me from doing an MDT examination, think he is an excellent candidate for MDT as this is obviously mechanical. Would most likely start him in supine (with/without HP for sx control/muscle relaxation) and several pillows to accomodate deformity just as we do with acute lumbar kyphotic deformity. I would then slowly take pillows out as his sx hopefully subsided over 1-2 hours hopefully to the point we could begin doing retractions in supine. Depending on how he responded and the mechanical changes that occured I would either send him home with sustained retraction several times per day and/or cervical retraction in supine vs. sitting. Goal of restoring full cervical lordosis and heavy education of avoiding static, protruded positions, and posture correct. Should do very well unless during correction he goes lateral then will have to treat lateral component and then return to sagital. I guess we will see, good case Chris.

  16. June 20, 2012 at 8:40 PM

    DJK said:

    OMG Not to be insulting, but 70% of the responses here reflect no working knowledge of the McKenzie approach. Again, Michael has it right. This is not complicated. Get a provisional treatment principle based on TESTING and go.

  17. June 20, 2012 at 8:14 PM

    Kay Scanlon said:

    There is no need for radiographs due to the absence of trauma. No red flags to suggest that further diagnostic testing is required. Acute loss of motion occuring for NAR is consistent with derangement. Proceed with mechanical assessment while observing mechanical and symptomatic changes.(as always) May need to unload (supine or prone) due to severe nature of patient’s complaints, with goals to return to loaded as able to patient is able to self treat.
    Since his posture is one of severe forward head,(upper cervical extension/lower cervical flexion) expect he will require retraction (upper cervical flexion/ mid range lower cervical extension) to reduce tje derangement successfully, however, this will be borne out during repeated movement examination. Spend some time assessing effects of postural correction to demonstrate cause and effect. Provisional classification: derangement, Direction: retraction. Lots of time educating patient about effects of sustained/flexed posturres so patient learns cause of this occurrence.

    These cases often are scary both to the patient AND the therapist. As long as one adheres to the principles and stops in the presence of worsening symptoms, the assessment is extremely safe and one that should be afforded ALL patients with acute onset of pain for NAR with no red flags present. These are the patients that end up going up for months and months of care with negligible relief of symptoms and end up with loss of function and fear of reinjury.

  18. June 20, 2012 at 8:10 PM

    Chris Chase said:

    Thank for all the great replies. I will not be able to respond to each individual response, but will try to cover common themes by addressing the 4 prior questions.

    1. Most think it is ok to proceed with the evaluative process but some do think x-ray or other consultation is warranted. Something to consider. This patient was seen by an MD hours before attending this session. If you are going to recommend imaging then, you must have a valid concern as you will risk alienating yourself from this MD and confusing the patient by recommending further imaging at this point. If there were red flags present, a significant unreported trauma, or significant neurological signs present than I would consider those valid reasons. In this case I see no reason not to progress with our assessment, but as with any acute spinal deformities, I would stop if the presentation changes.

    2. Remember this is only a “provisional” mechanical classification as you will attempt to confirm it with our objective portion of the exam. While there are a few comments suggesting pelvic and other causes for neck pain, I will stick with examination of the neck as the patient responded to lower cervical treatment, and it is unfair for my to comment on things not assessed. A number of comments suggest a cervical derangement which implies an acute displacement of the normal resting position of his lower cervical spine. This will be looked at during his examination next week.

    3. No one is suggesting aggressive treatment which I am happy to hear. In my experience spinal deformities need time, static positions, and gentle movement initially to successfully treat and classify.

    4. Numerous comments suggest unloading and working on extension principle or retraction exercises? A few people have suggested various manual therapy interventions to reduce pain and spasm as well as modalities. Are there any other additions or suggestions to compliment the mentioned interventions?

    Thanks again to all for the great comments. I look forward to ongoing dialogue and sharing the rest of the evaluation, the treatment and finally the outcome.

    Chris Chase

    • June 21, 2012 at 8:26 PM

      Tammy Suyematsu said:

      Very interesting reading all of the various comments. I definitely agree that using a MDT evaluation /treatment is the best option. The findings will determine the correct method of treatment.
      I also agree with someone’s comment that the use of McKenzie based treatment can get watered down. And this can be determined from some of the comments.
      I agree that there are some really scary answers out there!!
      As far as proceeding Chris, I was suprised that no one has mentioned having the Pt work in a loaded position first. Generally with the neck, you try to keep them loaded (they often respond better ) . Now that will be determined by results of repeated movements and he may have to be in an unloaded position if no improvement is noted in sitting. ( or of course worsening of sxs)
      thanks for your postings

  19. June 20, 2012 at 6:35 PM

    Ed O. said:

    1. Proceed with MDT exam
    2. Derangement
    3. Proceed with limited vigor
    4. Unload, accommodate the deformity then proceed with extension principle to try to establish directional preference.

    Or just give it few days and sees if spontaneously resolves.

    • June 20, 2012 at 9:52 PM

      JOHNL said:

      ditto. yes ED! I agree

  20. June 20, 2012 at 4:55 PM

    Jim Reilly, PT said:

    Jim R.
    A clear derangement from facts presented, I agree with recommendations to begin with unloaded retractions. I have had success elevating the head on folded towels at first, allowing the patient to work into the derangement zone. segmentally. It is clear, with his kyphosis, that the segment may react negatively at first, so moving above it to prepare the area acclimates it better. Passive lying with a cervical roll may also benefit the patient.

  21. June 20, 2012 at 6:14 AM

    Matthew Rupiper said:

    I would appreciate research on the statistical properties (reliability, validity, +LR/-LR, Sensitivity/Specificity) for tests/examination procedures mentioned here, specifically; palpation driven measures, supine to long sit test, and leg length assessment. I would also appreciate any research showing we can change posture, alignment, joint position in any condition that results in superior outcomes. Lastly, high level evidence to support the ‘mechanical diagnosis and treatment’ methods for cervical pain.

    • RSH said:

      June 20, 2012 at 8:04 PM

      If you are demanding high level evidence in order for anything to be applied to a patient in physical therapy then PT as a profession wouldn’t exist. 20 years ago the same demands regarding “mechanical diagnosis and treatment” for the lumbar spine were made. We now have strong evidence for classification, centralization and directional preference in the lumbar spine (Long 2000) (Doneleson 1990) (Wereneke 2004) among many more. We all know that available cervical evidence lags far behind that of lumbar. What’s the evidence for multilevel fusions that are being performed with ever increasing frequency in this country?

      “Mechanical Diagnosis and Therapy” depends wholly on signs and symptoms and relies heavily on patient education which I believe you acknowledged in your previous post. Centralization is seen just as clearly in the C spine as it is in the lumbar. Centralization has been demonstrated to be associated with improvement in pain intensity and function in cervical spine patients (Werneke et al, 1999) (Wereeke et al, 2008). The evidence in the Cspine is not as voluminous as the lumbar spine but some certainly exists.

      In the absence of overwhelming evidence for, and no hard evidence against, maybe common sense and experience has a place. If nothing is ever performed without evidence than how will the evidence ever be collected?

  22. Larry Davis, PT said:

    June 20, 2012 at 4:36 AM

    I would begin my examination by looking at the big picture. Is there a postural imbalance or asymmetry affecting the cervical spine? I have learned that scoliosis due to apparent unequal leg lengths often causes cervical spine pain and limited AROM. I recall a patient that had similar symptoms and very limited motion of her neck. She also had a palpable and visible “lump” on her c spine. After finding an apparent leg length difference related to pelvic asymmetry and correcting that using the DonTigny approach, her c spine AROM was nearly normal, and she reported minimal discomfort. When I saw her again for follow up, her posture was completely normal, and her C spine AROM was full and pain-free. This approach carries minimal risk, because the pelvic correction doesn’t involve any manual manipulation of the c spine.

    • June 20, 2012 at 6:29 PM

      mk said:

      Are you serious???? You are kidding right??? leg length???? pelvic asymmetry??? for what appears to be an acute derangement syndrome you are looking at leg length and the pelvis. Seriously????

  23. Jim said:

    June 20, 2012 at 3:41 AM

    Appears to be a derangement and I would proceed with mechanical evaluation. Initial thought would be to utilize extension principle every 1-2 hours. I would also educate re: posture’s roll in symptom management including use of rolls … Cervical and lumbar. Reassess as appropriate and hopefully recover remaining mobility soon.

  24. June 19, 2012 at 10:46 PM

    Beth said:

    I agree with derangement, extension principle as stated previously. Great blog and professional discussion.

  25. June 19, 2012 at 10:26 PM

    Amie said:

    No need for x-rays due to no trauma. Upper traps very likely in spasm. US would be of great benfit in relaxing them prior to doing AA rotation and sidebending in painfree ranges with gentle home program consisting of gentle AROM and postural and gentle isometrics if tolerated to start. He likely needs postural education for sleep. Ask how many pillows he uses at night. Too often sleeping with head/neck out of neutral due to too many pillows.

  26. June 19, 2012 at 10:19 PM

    Hilary said:

    I broadly agree with Roger, but suggest a milder approach:
    1.Is it safe to progress to a mechanical evaluation of his neck?
    From the history of onset, I would be evaluating his legs/pelvis and thinking muscle chains/connective tissue rather than neck function to begin with – iliopsoas and quads in particular- but include lower legs and feet. The mechanical evaluation of the neck would happen when his general posture was corrected.
    2.What provisional mechanical classification would we place him in?
    3.How aggressive are we going to be in our assessment and treatment?
    Gentle, muscle release, tendon release and handling techniques … here is a person in acute pain and traumatized.
    4.What direction and force would we like to treat him with?
    I would use Putkisto techniques of core alignment (centre, level, floors) to release iliopsoas in supine, crook lying with pillow support as necessary under head and knees. Release of flexors to flat and over subsequent sessions into increasing extension.
    Assisted hip flexion is used rather than force.

    • June 22, 2012 at 6:56 AM

      RSH said:

      Why in the world would you be “evaluating” this persons legs/pelvis and thinking muscle chains, not that I have the sightless idea what that means. What would his illiopsoas, quads and feet, have to do with an obvious lower cervical problem? What are Pukisto techniques?
      I have practiced for more than 30 years and your response and thinking concerns me.

      If a person presented with knee pain would you then finally look at the neck?

  27. June 19, 2012 at 10:13 PM

    Sergio zappala said:

    I would say it is safe to do a mechanical
    Evaluation to see if this person has a directional preference. The patient should be told that we are looking to find positions/ movement patterns that decrease pain and increase AROM. I would
    Assess cervical AROM, perform functional AROM TESTING TO HELP IDENTIFY JOINT MOBILTY T/o upper, mid and lower c spine. I would also test spinal accessory movements of all Cx and thoracic seg’s. As long as the pt. is given proper informed consent and told nothing should cause pain, there really is no need
    p, and also assessi spinal accessory movements of the c spine and t spine.

  28. June 19, 2012 at 8:45 PM

    Matthew Rupiper said:

    1. Pt. is negative for red flags suggestive of cervical myelopathy, neoplastic conditions, VBI or inflammatory/systemic conditions (Childs et al. 2004). Pt. demonstrates signs/symptom consistent with upper cervical instability without previous incident/injury (severe limitation in ROM). This could be ruled in/out with a Sharp-Purser test (SpPin: 96% and SnNout: 88% {Sizer et al, 2007}). The inability to rotate the c-spine 45 degrees and mid-line c-spine pain would suggest the use of a radiograph (Stiell et al. 2001), however there was no insult based on report patient history to suggest a fracture, ligament rupture, etc. Based on a paper by Sizer et al., 2007, this patient does not clear category I, II or III findings for the cervical spine.

    2. I don’t see the need to place the patient into a ‘mechanical classification’ secondary to a clear lack of evidence supporting this approach in patient’s with neck pain. The evidence supports a signs/symptoms approach (See Walker et al. 2008), regional approach (see thoracic spine manual intervention). As Gary suggests, education is also very beneficial for a patient with this presention.

    3. Treatment/intervention should progress to the patient’s presentation.

    4. Force, direction, and mode of intervention have not been demonstrated to matter in the cervical spine with high quality RCTs (see Walker et al. 2008). No appreciable difference has been demonstrated to further warrant the use of an HVLA vs. a mobilization (Leaver, 2010, Hurwitz, 2002). A recent RCT suggests taping has similar effectiveness to HVLA in the c-spine (Hernandez, 2012).

  29. June 19, 2012 at 8:08 PM

    Melinda H. said:

    I totally agree with Mike B – Patient had no blow to the neck thus no likely fx and is perfect candidate for Mechanical evaluation and treatment – of course moving very slowly and monitoring response. Positioning is also key – sending him home with positioning techniques to unload and support the C-Spine and would add Ice massage to the mix for inflammation and pain. Have had good success moving slowly with this type of patient, using Mckenzie principles.

  30. June 19, 2012 at 7:32 PM

    Mike B said:

    Agree with Michael. It is safe to begin a mechanical exam of the neck. There is no indication in the history that insidious pathology is likely to be present, nor is there any indication that there is any neurological involvement. There was no trauma, and it is extremely unlikely there is any damage to the bones. He is young and otherwise healthy. Therefore, no imaging is necessary at this point. Is it possible that he has some kind of pathology that is inappropriate for PT? Of course, but why spend tons of money and time testing for things that are incredibly unlikely. That would only delay getting this guy the help he needs, and possibly allow neurological deficits to develop.
    So the provisional classification is derangement syndrome. We would be extremely cautious with our mechanical exam due to the severity of symptoms and the observed kyphotic deformity. The direction and force would be unloaded retractions, mid-range at first, progressing to end-range as able based on symptomatic and mechanical responses.

  31. June 19, 2012 at 7:21 PM

    katrina kerr said:

    I would assessed as best possible with pain, range of motion and function. Pain and muscle spasm can be treated with a modality such as hot pack or ice pack, tens etc. An Xray would assist in proper management.

  32. June 19, 2012 at 6:47 PM

    theartofsciences said:

    Mr Chase,
    I would not touch the neck of this patient unless there was an Xray done prior to my own phystioherapeutic examination.
    I maybe the ONLY physiotherapeut on earth who would refuse touching an unkown patient without a go ahead, clean bill of health of cervical bony or neurological structures (including oncology) before pursuing my work, yet I would still maintain my professional opinion.

    Let’s say the cervical spine has been damaged, therefore, there won’t be any need for Physiotherapy until the bones are healed adequately and/or orthopaedic surgey has taken place.
    I would also ask for a neurological assessment for central neurological damage in which increase muscle tension might appear increased and also test for meningitis.

    If the orthopaedics and neurological tests come back clear.
    And so if the cervical bones and intervetebral joints are intact and there is no meningits or other central neurological damages from the lab results, then a physiotherapeutic assessment is indicated.

    I would try and relax the neck muscles while assessing where, in the joint range of motion, the pain is triggered.
    This I would do with a hand towel mobilisation while the patient is in supine lying, which not only relax patients and their cervical muscles, yet provides me with important clues about passive range of motion of the cervical spine and dissociate the shoulder from the cervical spinal joints. And after I would also assess the passive and active range of motions of both shoulders. The balance between abdominals and spinal extensors muscles.
    I would, of course, ask the patient what kind of work or activities, he was doing when his neck stiffneck began and what in general, his occupations are, including work.

    I would ascertain throughout that an ankle injury is not a neck injury and that swollen in the ankle area is not to be treated with as much ease as a potential central neurological disorder or/and other central disorders of the cervical spine or CNS.


    Paule Morbois

    • June 21, 2012 at 5:47 AM

      Jim said:

      Be confident and assess

      • June 21, 2012 at 3:58 PM

        theartofsciences said:

        NO. My confidence will confirm what I wrote in my first post: I will not assess a person, any patient with cervical pain or problem without an Xray.
        it is not because a Physiotherapist refuse to assess a patient without xray that the physiotherapis laks confidence, sometimes it is the contrary, over confident Physiotherapists will begin treatment/assessment on the basis that 99% of the cases referred to Physiotherapy are straight forward and there is no underlying damages which could be aggravated by Physiotherapy manipulation.

        What if THIS case was that very 1% which breaks the rule? Would I want to throw my career, professionel reputation AND most importantly the live or health of the patient?

        I WANT an XRAY.

      • June 21, 2012 at 6:54 PM

        Jim said:

        More often than not a good subj assessment will suggest something more sinister. If you’re concerned with stability, test it. I highly doubt and I believe the literature would support that oncological issues would be extremely rare here and the MD would have screened that … They don’t wish to toss their career either. Further more, the diagnostic imaging is static so would you have a clear unstanding of mechanics anyway? If your thinking tumor, etc, again given hx I believe it’s overkill. Assess and if something’s not making sense then you have an aurgument.

      • June 21, 2012 at 8:44 PM

        theartofsciences said:

        I don’t think any doctor or physiotherapist would wish tooss their career either. However, what too often happens is the over confidence some practioners develop with the years of practice (by practitioners, I mean any healthcare professionel) then there is the routine practice which also takes place. What if this one patient was the 1% out of the norm?

        The patient is a rock climber, 34 year old and in the introduction from Mr Chase wrote, and I quote:” the transition from one position to another was extremely painful”. Someone who spends hours in contorsions, someone with a well developped muscle bulk overall, someone who can probably carry his own weight at the tip of his own fingers. After sleeping in his car, he can’t change position without “extreme pain”.
        Does this paragraph makes sense?

        Xray would provide clues on neurological underlying problems, clues on mechanical problems and clues about potential oncological problems, yes.
        It does not take long to have an Xray done.
        What if the patient has a cervical hernia (very rare) wouldn’t it be wise to have an Xray?
        Would you practice MDT on a patient with cervical hernia?

        I want an Xray.

        Paule Morbois
        Meise, Belgium

  33. June 19, 2012 at 6:05 PM

    Herschel Budlow PT said:

    Given the brief history and the appearance of the patient, I would suggest the patient undergo immediate x-ray examination tto determine if there is a possible subluxation or other cervical spine abnormality that would preclude any mechanical evaluation by the physical therapist. I am sure many of us have seen an analagous situation in SI joint malalignments with a similiar onset – long car ride and sitting/sleeping in an awkward or mechanically-incorrect posture.

  34. June 19, 2012 at 5:43 PM

    Gary Diny said:

    Certainly see no reason based on information provided to proceed with evaluation. No certain it needs to be “mechanically” based exclusively. Not sure that the classification really matters. As for questions 3 and 4, the words aggressive and force will be greatly determined by how the evaluation process is progressing and how things are changing. I think some education on pain and pain physiology, likelyhood that no structural damage has occured given no trauma.

  35. June 19, 2012 at 5:37 PM

    Roger C. Skovly, PT, MA said:

    This is forward head posturing and is associated with an elevated pubic symphysis. With the patient in backlying, I would start by comparing the extremity lengths at the medial malleoli and correct any pubic symphysis malalignment/differences in the extremity lengths by descending the pubes using the appropriate manual muscle energy technique (manually forcing the short extremity into extension with the hip in 90 degrees hip flexion while the patient resists (isometric contraction). Once the pubes are descended, position the patient in prone, begin working on getting more mobility and extension of L5 on S1 using manual mob techniques, prone on elbows extension, and manual stretching. The whole idea is to get more extension of the entire spine and the head will the re-position to a more extended/balanced position. So use manual mobilization, passive and active stretching, manual traction the entire length of the spine, starting at the sacral base and moving upward to the suboccipital area.
    *Elevated pubes results when forces are directed upward through the lower extremities to the pelvis (runners, lifters, climbers, one-legged standing) or when forces are applies directly to the pelvis (ishial tubs) during sitting. Patient’s should be taught proper sitting posture that includes bearing weight on their posterior thighs as well as their ishial tubs.

  36. June 19, 2012 at 3:52 PM

    michael said:

    straight to the point: derangement syndrome. extension principle. unloaded cervical retractions, reassess how repeated unloaded retractions influence other motions, progress to loaded cervical retractions if no red light.

    • June 20, 2012 at 11:01 AM

      Sam said:

      I’m 100% agreeing with you, Michael! I don’t think x-ray is necessary b/c no trauma/injury/red flags. But always have “other” as classification on hand until confirmed derangement syndrome. Thanks Chris (and everyone) for spearing heading this blog!

      • June 20, 2012 at 6:50 PM

        mk said:

        sam agreed. remember it is a PROVISIONAL classification. the follow up will help to support it or not. but thanks for the input bc some of these comments are scary.

  37. June 19, 2012 at 3:08 PM

    Kitiana Chute said:

    I would probably recommend an X-Ray first, to clear the possibility of any joint disorder, then go ahead with a thorough neck assessment.

    If his X-ray is clear, my guess is its more of a postural disorder, aggravated by his sleeping position.

    I would first work on correcting his posture, then try relaxing his muscles with gentle frictions to his neck musculature extending from base of skull(trapezius) to upper back(trapezius,erector spinae muscles,lev scapulae), then ice application after massage.

    Direction?? but force would definitely be gentle.

  38. June 19, 2012 at 3:29 AM

    Leon Richard said:

    I’d go ahead and do an examination, including active range of motion and palpation of intersegmental motion to assess where the mechanical dysfunction is, if there is in fact one present.

    With all the muscle spasm and guarding contributing to the “spear tacklers’ neck” seen in the image… maybe all it will take is some light manual traction and some easy muscle energy and mobilizations to get the spasm to ease and things to quiet back down.

    No amount of force will “fix” this while the muscle guarding and spasm is this extreme.

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