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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.

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!



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?

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!



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?

And now… introducing Mr. G!

Dr. Marilyn Pink introduces Mr. G, our rTSA case study at 10 weeks post-op.

“As I reflected on the recent months and the extreme pain and aggravation I was experiencing, the thought of how yet one more orthopaedic surgery really bothered me. I specifically recall sitting in my car after picking up the MRI report, reading it multiple times and concluding – ‘all hope is lost’ (remember: I am a marketing major, not a scientist or medical person).

“I couldn’t wait to see Dr. Itamura and get his thoughts, although I must tell you that I did enough searching on the internet to bet on what Dr. Itamura would say and actually felt relieved when he indicated I was an ideal candidate for the rTSA.

“But before I proceed, I would like to take the stage for a bit and thank every single PT/PTA who has helped me in the past (and YOUR blog posts are part of that help!) and will be there for me in the future. You guys are great!  My mantra is that ‘if you are ever invited to a party with a PT – go!!! I’ve never met such a fun loving, honest, giving group of people.

“In particular, I’d like to thank Mark, Renee, Brenda, Fred, Crystal (whose every present greeting and smile set the tone for the balance of my visit) and all of you guys at Seven Oaks. You are absolutely the best and have shared in my challenges.

“So, back to my shoulder. If I’ve learned one thing, it’s that surgery is only half the battle: rehabilitation is the other. Now with the rTSA, I have completed six weeks of an exercise regimen which has increased my ROM and I remain completely pain free.

“It is a long haul and I know I am going to be careful with my shoulder FOR THE REST OF MY LIFE!  But, I can adjust to that. Instead of doing a mile freestyle in the pool, I am going to join an aqua-aerobics class. With Dr. Itamura’s permission, I am continuing with Pilates, long walks (hopefully bicycling in the future, but we’ll have to see about that), an adjusted weight training program and I’m going to start on a balance program (I don’t want to fall with all this metal in me!). I will adjust and continue living healthy.

“So, many thanks to Dr. Itamura and to all of you PTs who have helped me. I give you guys problems and you give me solutions.”

— Alan G.

Alan G.* Strengthening Principles in aging by Dr. Dale Evers is one of EDUCATA’s most popular lectures. If you are interested in a special promotion currently available on  this course, please contact our administrator at

So… off to a Reverse Total Shoulder (rTSA)

Two quick paragraphs as a prelude to the next steps in the Case:

  1.  Once again, I have to start off by saying how impressed I am with your thought processes and professionalism.  I’ve received many private emails from PTs who are learning from all of you who comment (as a matter of fact, the over 2,000 page views within the first 24 hours of posting indicates people are really interested in what you have to say!)
  2. I’m going to interject a wee bit about myself here:  while I am very comfortable with the shoulder (especially with sports and biomechanics) I am BY NO MEANS an expert in the kind of case presented here.  This case was purposefully selected so the YOU have a place to educate all of us.  So, Thanks, on behalf of all of us PTs!

Now, back to the Case:

As many of you wrote, the MRI indicated a need for referral to an orthopaedic surgeon who performs rTSAs.  The reverse total shoulder is a ‘last chance’ procedure for folks without much rotator cuff.  And, Mr. G. clearly was lacking in the rotator cuff department.  Candidates for the rTSA need to be medically sound and have demonstrated precise follow-through to instructions/limitations post surgery.  Because if something happens to the rTSA, there is no re-do —- there is no second chance with it.

The rTSA entails the ‘ball’ of the socket to be inserted into the scapula and the ‘dish’ of the joint into the humerus (you can see that in the x-ray above – and some of the references below give even clearer pictures).

This is a relatively new procedure and Mr. G. was encouraged to interview multiple surgeons, ask about the number of rTSA procedures each surgeon performs and the outcomes.   Fortunately for Mr. G., one of the surgeons is a leader in the field of rTSA, a member of the American Shoulder and Elbow Surgeons, has performed research, does over 160 rTSA’s/year and has excellent outcomes.  Dr. Itamura is an Associate Professor of Clinical Orthopaedic Surgery at the University of Southern California  School of Medicine, Department of Orthopaedics.  Operating room staff and therapy staff also recommended Dr. Itamura without reservation.

Here is a word from his surgeon, Dr. John Itamura:

Mr. G. was an ideal candidate for the rTSA.  First of all, he is medically sound.  This is a difficult procedure and if he had had medical co-morbidities, I would not have done the procedure on him.  Secondly, his lack of rotator cuff make the rTSA the most viable procedure.  Third, he has had other total joint replacements, so he knows what it will take to get back on the road.  He is aware that it will take a year before we know exactly how far he will progress.  Fourth, he listens.  I believe he will be very conservative and careful with his reconstruction.  Even though he is basically an over-achiever with exercise, the consequences of that have been explained to him and he agrees not to overdo things.  He knows there is no second chance at this point. 

I’m not a big proponent of PT for the rTSA, since conservatism is the route I go. And if the patient does receive PT, it HAS to be slow, easy and the patient must listen carefully to the therapist – so, we’d need to all be on the same page. I have my patients perform the Anterior Deltoid Exercises for Patients with Massive Rotator Cuff Tears 5 times a day (the reference for that is below). Yet, I know other excellent surgeons are more aggressive. Boudreau et al 2007, JOSPT (which is not research, but a Clinical Commentary) is much more aggressive than I choose to be at this point, and there are surgeons who go that route.  But, give me some evidence, and I’m happy to reconsider — I may do some research on the rehab myself!

For four weeks post-op, Mr. G. wore an abduction splint (image above), even at night.  After 4 weeks in the splint, here is the resting position of his arm (image below).  At 6 weeks post op, his arm had naturally dropped to < 10 degrees of abduction.

physical therapy continuing education shoulder deltoid shortening

Now, as a member of American Shoulder and Elbow Surgeons myself, I see a huge difference in rehab opinions even among this specialized group of orthopaedic surgeons.  However, in my simple opinion, I’d still like to do some work on Mr. G.’s scapular stabilization.  So, once again, armed with literature, Dr. Itamura and I are scheduled to meet the end of this month.  We will discuss scapular mechanics, the effect of lack of scapular stabilization (Dr. Jacquelin Perry calls it a ‘floating scapula’) on the axis of rotation (and how that may affect the longevity of the prosthesis as well as the success of the outcomes), the probable fact that Mr. G. has been using his anterior deltoid (hence ‘retraining’) in place of his rotator cuff for years (thus some questionability about the ‘anterior deltoid’ retraining as seen in and the potential for precise, practical, low risk scapular exercises for Mr. G. – and all folks receiving a rTSA.  Dr. Itamura and I may actually do some research on this since I suspect Mr. G. is not alone – that most rTSA candidates have been ‘re-educating’ their deltoids for awhile and I’d hypothesize that a large percentage of these patients have a ‘floating scapula’ (i.e. not enough scapular stabilization to allow for precision in the axis of rotation with humeral motion.)

So, we will see where that goes!

Here are some articles available for you regarding the rTSA. Unfortunately, there is very limited evidence based information out there (probably because the procedure is relatively new – it was performed in Europe for about 20 years before it was approved by the FDA in the United States). These articles are available for free as part of the physical therapy continuing education resources at EDUCATA’s library. You will need to log in, but membership is free too.

  1. Consequences of scapular anatomy for reversed total shoulder arthroplasty
    By: Middernacht B, De Roo PJ, Van Maele G, De Wilde LF.
    Clin Orthop Relat Res. 2008 Jun;466(6):1410-8.
  2. Contribution of the reverse endoprosthesis to glenohumeral kinematics
    By: Bergmann JH, de Leeuw M, Janssen TW, Veeger DH, Willems WJ.
    Clin Orthop Relat Res. 2008 Mar;466(3):594-8.
  3. Evolution of the reverse total shoulder prosthesis
    By: Jazayeri R, Kwon YW.
    Bull NYU Hosp Jt Dis. 2011;69(1):50-5.
  4. Reverse shoulder arthroplasty
    By: Smithers CJ, Young AA, Walch G.
    Curr Rev Musculoskelet Med. 2011 Dec;4(4):183-90.
  5. Rotator cuff deficient arthritis of the glenohumeral joint
    By: Macaulay AA, Greiwe RM, Bigliani LU.
    Clin Orthop Surg. 2010 Dec;2(4):196-202.
  6. Total shoulder arthroplasty
    By: Sanchez-Sotelo J.
    Open Orthop J. 2011 Mar 16;5:106-14.
  7. What is a successful outcome following reverse total shoulder arthroplasty?
    By: Roy JS, Macdermid JC, Goel D, Faber KJ, Athwal GS, Drosdowech DS.
    Open Orthop J. 2010 Apr 23;4:157-63.

Additional resources include the following two articles as well as the exercises that Dr. Itamura utilizes.

Boudreau, S, Boudreau E, Higgins LD, Wilcox RB 3rd: Rehabilitation Following Reverse Total Shoulder Arthroplasty.  JOSPT, 37(12), 2007, 734-743 which is out of England and I think the exercises are there under  Physiotherapy.

All right – it’s YOUR TURN again!  I love reading your posts! What do you think should be done next?


Coming next week: Mr. G. discusses the outcome of his treatments and present condition

Shoulder Case Study #1: MRI results

Oh, Mr. G.  Not a pretty arm!

As many of you have mentioned, I too believed in the need for imaging tests and/or a referral to Ortho. I wanted anatomical knowledge BEFORE going down the wrong road (and using up his Medicare visits). There were way too many unknowns and the patient has a complex musculoskeletal history.

Thank-you, Dr. McFarland, for your viewpoint. You are a well respected (and well published!) orthopaedic surgeon with an excellent reputation with the shoulder. So, all of us PTs appreciate your unique input.

This case introduction was purposefully written with limited assessment information in order to see what YOU WOULD DO: to pull out your thought process with not only the assessment, but with the next steps. And your comments demonstrate a high degree of skill of which our profession can be proud. So thanks for filling in the intentional blanks so that your thought process can be a learning tool for all PTs –and given the number of visits to this blog, many have benefited from hearing from you!

Onward to what happened next. I did go back to Mr. G’s internist and suggested an orthopaedic referral;  and with all due respect to an orthopaedist, my opinion was that there would be a benefit from an MRI. The internist agreed. So, armed with a list of questions, Alan set out to interview several orthopaedists with a specialty in the shoulder. Interestingly, not all of these surgeons thought an MRI  nor any other tests were necessary prior to deciding the course of action (and for Alan, that ruled them out as a candidate to be HIS orthopaedist). One of the surgeons made it very clear to Alan that he couldn’t say what he’d do until he had an MRI.

If any of you are interested in Alan’s interview questions for the orthopaedists – and what made him ultimately select the one he did, just ask on the comments section and I’m sure the patient will be happy to respond to you.

Here are the results of that MRI:


  1. The supraspinatus tendon is torn with approximately 5 cm of proximal retraction of the musculotendinous junction.  Severe fatty atrophy is seen of the supraspinatus muscle (please see the MRI image, above).
  2. A high-grade partial tear is seen of the distal infraspinatus muscle predominately involving the joint side surface and this involves greater than 80% of the thickness of the infraspinatus tendon.
  3. The subscapularis tendon reveals severe tendinosis with thickening.
  4. Joint effusion is present with a large amount of fluid extending into the subacromial/subdeltoid space with distension of the subacromial/subdeltoid space.  The distension also extends anteriorly to involve the subcoracoid bursa.  Extensive synovial thickening is seen superior to the humeral head in the region of the supraspinatus tendon tear.
  5. The bones are notable for severe subchondral cystic changes involving the articulating surface of the humeral head, as well as the glenoid.  Denudation is seen of the articular cartilage with subchondral eburnation and large marginal osteophytes.  The entire labrum is severely degenerated..


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