Continuing Education Bits for PTs & PTAs

Archive for June, 2012

Central Cervical Pain case study, part II: EVALUATION

Intro: Wow! That was some interesting discussion!! Let’s hear it for Chris Chase in doing such a fine job of moderating! This professional blog is followed by MD’s, PTs and OTs.  It looks like most of the posts are, appropriately, by PTs. Yet, the following of this blog crosses many medical disciplines. For that reason, we ask that you give your name (rather than just initials) and your credentials, and know that you are as identifiable and professional as if you were at a conference. In the vein of utmost quality, we will be monitoring the posts, and only those professional posts with names attached to them will be funneled to the blog.

With that, I give you back to Chris Chase PT!  We look forward to your comments!

Marilyn

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.

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.

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

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 Lateral Flexion: major loss in both directions with pain.

At this point, it is time to decide to how to initiate treatment. A number of different treatment strategies have been suggested, but at this point I would like to know specifically how you would proceed.

  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?
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How Would You Treat a Patient with Central Cervical Pain and Acute Kyphotic Deformity? (a case study)

By guest blogger Chris Chase

Chris Chase PTI’m so pleased to introduce you to guest blogger Chris Chase PT — Chris is not only an outstanding PT, but he also provides continuing education courses for St. David’s Rehab Hospital.

In this series of posts, Chris will discuss the case of a patient that came to him with severe cervical pain, expose the course of treatment, and show you the results, with lots of “before” and “after” images.

As always, we invite (encourage!) your participation and comments on how you would approach the patient, knowing that collaborative international knowledge has lead us to fantastic new viewpoints!

Enjoy the case study! And now, I give you Chris Chase!

Marilyn

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.

Central cervical pain acute Kyphotic deformity

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, and I’d like your thoughts. And stay tuned because over the next weeks we will move onto the eval, then the treatment to end with a review the outcomes. 

  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?
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