1. July 6, 2012 at 12:43 AM

    Philip Paul Tygiel PT, MTC said:

    Nice work and good initial result. I suspect you might have gotten the same result more quickly had you done something to modulate the pain first but whatever works for you is good.

    Jocelyn’s point about addressing the trunk is well taken and evidence now indicates that manipulation of several segments in the thoracic spine of a patient with cervical problems does provide significant relief. The mechanism is not completely clear but I suspect it reduces some postural stress which then allows you to more easily address the primary cervical problem. It is also possible there is some endorphin release. In any case it is certainly worth a try if the manipulation can be done easily and in a pain free range.

    1. Is the provisional classification of derangement correct and, if so, what is our primary goal?

    For those who are strict adherents to Robin McKenzie’s approach the provisional classification of derangement would certainly fit here. While I do certainly agree with McKenzie’s assessment and treatment regimes and the results you get using them, I have always questioned whether or not he is correct in his pathology hypothesis. As he explained it to me, many years ago, the idea of “disc derangement” was predicated on the concept that somehow the nucleus was getting stuck in a position that would not allow return to full range of motion. Given that the nucleus, especially in a younger person, acts as a gas or fluid under pressure and that such matter usually assumes the shape of its container rather than dictates it, we should at least question the derangement concept (just something to think about). At best we can only speculate that this is derangement as there are no definitive tests that will confirm any of the diagnoses we might consider.In any case I think most of us are in agreement that this is most likely a mechanical, musculoskeletal problem that should respond well to mechanical correction. Also if he does respond well to the treatment it doesn’t really matter what the true diagnosis was.

    2.What is Shawn’s home exercise program and is there any other special advice that needs to be given?

    Whatever active exercise can be done going through the full painfree range. I’d prefer to have the exercise done in the upright position if possible with the deep neck flexors engaged in postural control but if they can only be done pain free in suppine that is where I would have him start. The other advice is to stay as active as possible.

    What is Shawn’s prognosis and do we expect a slow or fast recovery?

    Shawn begins with an excellent prognosis. Lets face it. Even if we did nothing for him he had an 85% chance of full recoverey. The fact that he was fortunate enough to begin active physical therapy so soon after onset increases his chance of full recovery to 98%. The Linton Study demonstrated that years ago.

    This does raise some new questions for us to think about that it would be good to address before we know the final outcome.

    1. If Shawn doesn’t improve fairly rapidly what other pathological conditions might we consider to be at play?

    2. If Shawn isn’t improving or is improving very slowly, how long would we treat him before seeking other diagnostic tests?

    3. If Shawn is not improving what other diagnostic tests would we order and why? (This last question is extremely pertinent right now as the APTA just adopted a position saying that physical therapists should be able to order various tests and imaging studies.)

    Thank you for starting this conversationand giving us so much to think about.

  2. July 4, 2012 at 6:52 PM

    Jocelyn, PT said:

    It appears that his trunk is quite restricted – ribs, abdominal area. The pulling in the front is affecting his neck. I would suggest those areas be addressed as well.

  3. July 3, 2012 at 7:59 PM

    Kay Scanlon said:

    I think what is the valuable lesson here is that deformities require time and often unloading to reduce. It is important to continue with the reductive force while all the while monitoring symptoms. The therapist AND the patient can both be assured it is the correct direction by rechecking mechanical (movement) and symptomatic baslines.

  4. July 3, 2012 at 7:48 PM

    Barbara said:

    I think that Shawn will have a fast recovery.
    For his homework I would give him the exercice on the table (retraction , bit also with rotations maybe some PNF – diagonal movements )

  5. July 3, 2012 at 4:54 PM

    Scott Belding, PT, Cert MDT said:

    I would concur with Ed Orloff’s summary. I would add sleep instruction…cervical roll with one thin pillow to maintain as much reduction as possible while sleeping in a neutral position. Also, encourage the patient to avoid heavy lifting!

  6. July 3, 2012 at 9:25 AM

    afolabi olusegun, PT, B.MR said:

    this is a very good work and discussion, first, i wasnt you to incoporate deep cervical muscles stabilization exercises, if its desarangment, there is a very good prognosis becos the pry goal is to reduce the kyphosis.
    pls at which cervical level is the kyhotic deformity?

  7. July 2, 2012 at 9:52 PM

    Nick Nordtvedt, PT, DPT, Cert MDT said:

    Great discussion! I think you can confirm at this point that this is derangement that should resolve rather quickly with a good prognosis. I wound’t say that he’s fully reduced until he returns the same or better for his next tx, so he is still in the reduction stage. Next would be to maintain the reduction followed by prophylaxis. HEP would be retraction extension in supine every 2 hours or more based on s/s. What I learned from this is just how long it can take for kyphotic deformities to reduce and then to ensure that they are actually getting to end range. I think that this can get lost in a fast paced clinic with a pt sent home prematurely to continue with just a retraction in lying HEP.


    • July 2, 2012 at 11:53 PM

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

      1. Provisional classification derangement with primary goal to maintain reduction.
      2. Keep with supine Ret and Ret/Ext each hour. Maintain posture with Lumbar roll. Specific avoidance of protruded/flexed position.
      3. Should be a quick recovery.


    • July 5, 2012 at 2:20 AM

      Carol Keenan said:

      I agree and would also recc cervical roll for sleeping (this could have contributed to the worsening over the initial 2 days. I self treated a recent cervical episode with extension and agressive A/A rotation and sidebending toward the symptomatic side (which produced centralization, but significant central pain!) I agree with the remarks about the busy clinic and the probable missed opportunities. This pt will have a very rapid recovery. Thank You McKenzie!!