C-Chase2 SMThis case study is presented by Chris Chase, PT, MSPT, FAAOMPT, Dip.MTD. Chris graduated from St. Louis University with both a Bachelor’s in Exercise Science and a Masters in Physical Therapy.  He has practiced at St. David’s Spine and Sports Therapy in Austin, Texas since 2009.  Before that he worked in private practice in orthopedic sports physical therapy in St. Louis, MO for over 10 years.  In addition to his clinical practice Chris is interested in collecting and reporting functional outcome measures, and provides continuing education courses for St. David’s Rehabilitation Hospital.

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PART 1 — INITIAL ASSESSMENT

Sean arrived at the clinic complaining of severe cervical pain (10/10) and limited motion secondary to pain. He could not turn his head side to side, look up or down, and any sudden movement, laugh, or transition from one position to another was extremely painful. His head was severely protruded and he was wincing in pain.

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Patient Evaluation: Lower Cervical Kyphotic Deformity

He is a 34 year old male, who has no prior history of neck or any spine problems.  He awoke with the pain two days before coming in, after sleeping in the back seat of his car when camping. He is an avid rock climber who exercises regularly and has never seen any medical professionals for any musculoskeletal injuries. That morning he had been assessed by his physician, who told him he had severe muscle spasm in his upper traps and gave him an exercise sheet for the treatment of acute torticollis which included numerous stretches. He was also given muscle relaxers to take if the physical therapy did not work. No diagnostic imaging was ordered.

The patient reported that two days prior, when he awoke, the pain was not as severe; it had also intensified significantly over the last 48 hours and was now limiting his range of motion. He was unsure how stiff it was when he first experienced symptoms but felt that his extreme loss of movement worsened over the last two days when  compared to when he first had pain.  His forward head deformity was unmistakable and even the task of getting out of the chair in the lobby to go to a treatment room was very painful.  Fortunately, his pain was central with no radiating symptoms or any numbness or tingling.  He did not report any difficulty with his vision, swallowing, coordination or tinnitus.  He had no symptoms of nausea or any other red flags and denied any car accidents, falls, or any trauma recently or ever in his life.

At this point a couple of critical questions come to my mind:

  1. Is it safe to progress to a mechanical evaluation of his neck?
  2. What provisional mechanical classification would we place him in?
  3. How aggressive are we going to be in our assessment and treatment?
  4. What direction and force would we like to treat him with?

Feel free to post your thoughts on this in the COMMENT field, below, or view other’s comments on this by clicking this link.

See prior comments to the INITIAL ASSESSMENT post.

PART II — EVALUATION

At the conclusion of the subjective history and performing a neuro exam that was negative, I decided to proceed with my mechanical assessment of Sean’s condition.  Because of the very sharp pain with transitions, I proceeded slowly with care and caution while constantly monitoring his symptoms for anything out of the ordinary. Typically, I initially perform postural correction and assess the effects. However, in this case any attempt to improve his sitting increased pain. Because of the forward position of his neck, he was most comfortable slouching –but even this was uncomfortable.

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Baseline sitting position

I observed the visible kyphosis as seen in the picture. It was not warm nor swollen, there was no redness noted and the patient was unaware of any pre-existing deformity as he described normally having excellent ROM that he used when rock climbing and during day-to-day activity. He did not demonstrate any significant muscle spasm or hypersensitivity, and reported only central pain during his movement portion of the exam.

Next I examined his Range of Motion.  His loss of motion is clearly illustrated in the following images:

Protrusion: Minimal loss. Even though he was stuck in this position, he could not protrude further into range of motion.

Protrusion: Minimal loss. Even though he was stuck in this position, he could not protrude further into range of motion.

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Retraction: Major loss or completely obstructed. He was unable to retract at all.

Flexion : Major loss with no movement coming from his lower cervical spine

Flexion: Major loss with no movement coming from his lower cervical spine

Extension: Major loss with minimal movement coming from his mid cervical spine and his lower spine was fixated in flexion.

Extension: Major loss with minimal movement coming from his mid cervical spine and his lower spine was fixated in flexion.

Right and Left Rotation: moderate loss in both directions, however, significant pain in both directions.

Right and Left Rotation: moderate loss in both directions, however, significant pain in both directions.

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Right and Left Lateral Flexion: major loss in both directions with pain.

Right and Left Lateral Flexion: major loss in both directions with pain.

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At this point, it is time to decide to how to initiate treatment.

  1. What specific direction would you start with in an attempt to restore his normal lordotic curve in his lower cervical spine? Or would you have a different initial treatment strategy?
  2. Once you have a direction, what particular loading strategy would you like to try? And why?
  3. Does manual therapy have a place in the treatment of this patient and if so, what techniques may you use?

Feel free to post your thoughts on this in the COMMENT field, below, or view other’s comments on this by clicking this link.

See previous comments to the EVALUATION section of this series.

PART III — TREATMENT

It is now time to begin treatment to see if we can assist Shawn with his painful condition.

Based on his sudden onset, his obstruction to movement, and constant pain presentation, I provisionally classified him as having a lower cervical derangement with kyphotic deformity and chose as the course of action the treatment outlined by Robin McKenzie. For this condition, it requires unloading the patient and attempting to reverse the forward flexed position of his lower cervical spine by moving into lower cervical extension gradually. It is recommended to start with the patient’s head accommodated into flexion, and I chose to use folded towels to control the degree of protrusion.

I had Shawn gently retract into the towels and as his pain slowly decreased, I then removed one towel at a time. He had slightly less pain in this position, so we started to move out of the forward flexed position, and his pain began to lessen significantly. The following pictures were taken over approximately 30 minutes of treatment with Shawn performing intermittent retraction into the towels, and eventually into the treatment table.

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Once Shawn achieved maximum retraction into the table, I began to push further extension off the table while cradling his head. At this point, gentle traction was applied while assisting his pain since gaining retraction was still quite slow and difficult.  It took a considerable amount of time and repetitions before he could get to end-range retraction off the end of the treatment table, and the degree of traction was slowly increased to promote increased lower cervical extension.

This took an additional 10-15 minutes.

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Shawn was returned to the upright seated position and his baselines were rechecked. His ROM was mildly better, but his pain was considerably less. Because it was still improving, overall, we agreed to continue treatment and  attempt further improvements.

The next progression recommended by the McKenzie Method is to apply extension to the lower cervical spine. I returned him to supine since seated movements were still obstructed. While attempting extension, I still applied traction as we worked into lower cervical retraction/extension because it was it was giving us a very good response. Slowly, his ROM improved to the point where I could fully extend him to end-range. Pain levels continued to decrease and became centralized to a very small area at the base of his neck.

Attaining full extension took at least another 15 minutes of repeating the movements in sets of approximately 8-10 repetitions with frequent breaks between sets. At this time, all efforts were made to prevent any protrusion or lower cervical flexion between sets of extensions.

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After repeating end range mobilization of his lower cervical spine into extension and before attempting sitting, Shawn was placed into sustained end-range extension three times for 1-2 minutes to ensure he had attained end-range extension. Throughout Shawn’s entire treatment, we were monitoring his pain intensity and location. At no point did things intensify or worsen. In addition, special attention was given to screening for any unusual findings including dizziness, nystagmus, visual disturbances, feelings of nausea, etc. None were reported, in fact, he could not believe how much better he was feeling as our treatment progressed.

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At this point, Shawn returned to the upright position with only slight central pain and approximately 50% better ROM. He was given a very specific home exercise program, ensuring he understood the precautions, and was instructed to return in 24 -48 hours for reassessment. He was also told to call the next morning if his pain worsened in any way.

So, at this time I’d like to pose these questions:

  1. Is the provisional classification of derangement correct and, if so, what is our primary goal?
  2. What is Shawn’s home exercise program and is there any other special advice that needs to be given?
  3. What is Shawn’s prognosis and do we expect a slow or fast recovery?

Feel free to post your thoughts on this in the COMMENT field, below, or view other’s comments on this by clicking this link.

See previous comments to the TREATMENT section.

PART IV — OUTCOME

I’d like to start this section by commenting that the provisional classification of derangement syndrome as defined by Robin McKenzie was confirmed. The initial treatment goal of a cervical derangement is to reduce the condition, and, as shown in Part III, we obtained rapid reduction of pain level and an increase in ROM. Part of full reduction means obtaining full ROM and removing obstruction to movement. For an acute derangement with a lower cervical kyphotic deformity, that means obtaining full lower cervical extension which we were able to reach during our first session.

Maintaining full extension will be challenging. So, exactly what home exercises will he do to maintain his reduction? I’d like to focus on two important themes:

  1. It is generally easier to perform self-treatment in sitting position, so whenever possible I tend to use seated exercises for my cervical patients. However…
  2. …deformities usually need to be treated supine due to the severe obstruction to movement.

I gave him two exercises and gave him specific advice about his sitting posture, sleeping posture, and avoiding prolonged flexion activities, especially computer work and while driving. I also instructed him to do his exercises hourly or as soon as he felt his ROM beginning to obstruct.  This may seem unreasonable but since the exercises only take a couple of minutes and will hopefully only need to be done for a few days at this frequency, it is practical.

Shawn was returned to the seated position and retraction and retraction/extension were attempted in an upright chair. Unfortunately even though his pain was only a 1/10 and he could rotate and sidebend better, loaded cervical retraction was quite difficult and still partially obstructed. He could perform both supine retraction and extension off the table but, since he desired to return to work by the following day, I wanted him to have an exercise available where he would not have to lie down. I had him stand against the wall to try retraction and his head bumped the wall, so I folded over a pillow and placed it across his shoulder blade area.

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With his thorax away from the wall he could perform retraction quite well and considerably better than when attempted in sitting. I instructed him to perform both retraction standing as well as supine retraction and supine extension for his self-treatment.

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With this condition, if he can maintain the extension, I generally expect quite a rapid recovery, although not all deformities can be treated quickly. Left untreated, this condition could deteriorate and potentially turn into a deformity of torticollis which is much more difficult to treat, and often takes longer.

Shawn and I exchanged emails in the ensuing hours. He reported 85% improvement, could move his head even better as the day progressed, and returned to work. I emphasized that, even though he felt better, he needed to maintain his self-treatment exercises and return for treatment the next day.

When he came in the following day (a bit over 48 hours from first assessment), he reported feeling 95% better even confessing that his exercises were not done as frequently as instructed given his rapidly improving condition. He never filled his prescription for muscle relaxers and was not taking any medications. I emphasized the importance of maintaining full pain-free ROM for at least one week before attempting flexion movements but told him he could decrease the frequency to 5-6 times a day –more if he felt increased pain or stiffness returning. Here are some images of his ROM gains 48 hours after initial assessment:

REASSESSMENT: RETRACTION

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REASSESSMENT: EXTENSION

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REASSESSMENT: FLEXION

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REASSESSMENT: RIGHT ROTATION

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REASSESSMENT: LEFT ROTATION

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REASSESSMENT: RIGHT SIDE-BEND

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REASSESSMENT: LEFT SIDE-BEND

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At this point I instructed Shawn to return in one week for further care, unless he became obstructed again, in which case he should call to get in immediately. At one week, he felt 100% back to normal and was only doing the exercises a few times a day. Flexion, rotation, and all movements were now pain-free and back to his pre-existing level of function.

According to treating the derangement model, the first order of business is to reduce the derangement, then maintain the reduction before performing recovery of function activities, and finally, to perform a preventative home program focused on maintaining full ROM, especially in the reductive direction (in this case, lower cervical extension) and continue to practice proper posture. Shawn was instructed what to do if his pain returned: avoid sleeping in extreme positions of flexion, break up static flexion activities (slouching ) with intermittent lower cervical extension, and to always end cervical stretching exercises his reductive exercise (retraction/extension). With ongoing practice of this advice, I anticipate a low chance of recurrence. However, Shawn has now been educated in how to self-manage and knows to get into PT right away if the problem returns and he cannot self-manage.

IN SUMMARY

There is much to be learned from the treatment of Shawn. Manual therapy can assist in treatment with gentle manual traction, but there is no need for manipulation or aggressive techniques. Once Shawn’s deformity was reduced, self treatment and good posture were very effective interventions emphasizing that there may not be a need for expensive modalities, numerous treatments, or outside referral. Shawn has continued to do well. Within two weeks, he was climbing again, exercising regularly, and even occasionally doing his exercises.

BIBLIOGRAPHY:

Articles:

  1. Hanney WJ, George SZ, Kolber MJ, Young I, Salamh PA, Cleland JA. Inter‐rater reliability of select physical examination procedures in patients with neck pain. Physiother Theory Pract. 2014 Jul;30(5):345‐52.
  2. Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention. Man Ther. 2014 Jun;19(3):222‐8.
  3. Caneiro JP, O’Sullivan P, Burnett A, et al. The influence of different sitting postures on head/neck posture and muscle activity. Man Ther. 2010 Feb;15(1):54‐60.
  4. Chaniotis SA. Clinical reasoning for a patient with neck and upper extremity symptoms: a case requiring referral. J Bodyw Mov Ther. 2012 Jul;16(3):359‐63.
  5. Takahashi H, Hall T, Kaneko S, Ikemoto Y, Jull G. A radiographic analysis of the influence of initial neck  posture on cervical segmental movement at end‐range extension in asymptomatic subjects. Man Ther. 2011 Feb;16(1):74‐9.
  6. Dunleavy K, Goldberg A. Comparison of cervical range of motion in two seated postural conditions in adults 50 or older with cervical pain. J Man Manip Ther. 2013 Feb;21(1):33‐9.

Books:

  1. McKenzie R, May S. The Cervical & Thoracic Spine: Mechanical Diagnosis and Therapy, Volumes 1 and 2. 2nd ed. Raumati Beach, New Zealand: Spinal Publications; 2006.

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This article has 5 comments

  1. beth crowell

    I have performed this same treatment with cervical patients. I have them use a half foam roller on the wall for postural holds.

  2. pramod kumar pradhan

    Good work and your effort in the field of Physiotherapy is really appreciated .

  3. Jordan Hoile, PT, DPT

    Great case study! Very informative and useful layout of evaluation, thought processes for treatment approach, and outcomes. I appreciate the work put into this, thank you!

  4. olusegun

    good work, very educative and also effective, I have tried it and it works. thanks to educata. HAPPY NEW YEAR TO ALL OF YOU

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