Continuing Education Bits for PTs & PTAs

Archive for July, 2012

And… The Results Are In! Part IV, Severe Central Cervical Pain Case Study

Chris Chase PTBy guest blogger Chris Chase

I’d like to start this fourth & final post by answering questions that came up. 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? Many great ideas were offered, and 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.

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.

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:








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.


There is much to be learned from the treatment  of Shawn. Be patient and attempt to restore extension slowly with this presentation. 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.

* * * * * *

Thank you to everyone who contributed to this case, as it was unveiled. I hope it was useful and informative and I look forward to any additional comments or questions. I have enjoyed my first blogging experience.


The “Three-step treadmill test and McKenzie mechanical diagnosis” paper is available for free to EDUCATA members. Not a member? No problem! Registration is easy and free — and has benefits!

The McKenzie Method course is approved for CE credits in most states and provides a great overview to this practice.

Part III: TREATMENT (central cervical pain case study)

Chris Chase PTBy guest blogger Chris Chase


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.

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.

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.

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.

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 throw it back to you:

  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?

I look forward to the ongoing discussion! In our fourth and final post I will share the results of Shawn’s treatment with photos of his ROM after 48 hours. I will also discuss the overall management of Shawn’s case and long term treatment plan.


This paper is available for free to EDUCATA members. Not a member? No problem! Registration is easy and free — and has benefits!

The McKenzie Method course is approved for CE credits in most states and provides a great overview to this practice.

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