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cervical spine HNP
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cervical spine HNP - September 6, 2004 9:06:00 AM
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eam
Posts: 290
Joined: February 5, 2004
From: New York, NY 10028
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Hi everybody-
I was wondering if anybody had some thoughts on a patient I am treating.
30 something female -pharmaceutical rep. s/p MVA (work related)- (about 1 1/2 months ago) out on disability. Motivated-has a degree in PT but never practiced. I have seen her for 4 visits so far.
MRI revealed mutli-level disc protrusions C2-C7. No LOC, dizziness etc. Current complaints are HA (intermittent), pain with FB and BB. (R>L) Rot and SB are normal and painfree. Ligamentous testing, vertebral artery testing -negative. FB is approx. 50% and BB is about 20% before pain sets in. In order to relieve the pain with extension the pt. rounds her shoulders and gets immediate relief. My view on that one is that just limits her overall extension anyway and that is why she feels better. Not sure, though. She had a positive median nerve (R) tension test and some segmental hypomobility in her upper/mid thoracic spine (R). Myotomal weakness (R) c5/6 and a hyper-reflexic triceps reflex on the right. Other than that, there seemed to be no significant mm guarding except in her mid thoracic p/s. SCM, scalenes, UT's all appeared normal. She did have some difficulty swallowing initially, just once. But this had not occured lately. I performed accessory (Paivm) and PIVM and nothing jumped out as being abnormal.
I have tried HA Snags on her with some success. Sub-max IM's also. Neural mobs (median) have been unsuccessful so far. I have been able to increase forward bend rom to about 70% (but carryover is poor). I am getting no where with extension. I am also doing some sub-occ, release and gentle manual traction. Initially, I did not want to do any kind of traction b/c of possible joint instability, ligamentous stretching etc.
Her current complaints of pain are really localized to the right mid -cervical spine. No scap pain or arm pain. She is wears a collar at night to sleep. Any thoughts would be appreciated. Thanks in advance!
Erica
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Re: cervical spine HNP - September 6, 2004 3:47:00 PM
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CarolinaPT
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Joined: May 6, 2004
From: North Carolina
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Hi Erica,
Does the patient have any visible multifidus atrophy? Patients, especially with whiplash type injuries, can end up with damage to their multifidus muscle which does not heal itself without retraining (sorry, I don't have the reference here). Typically, I add these type of exercises in when I see that type of mechanism of injury even though I do not have a tested defecit. I do not know of a way to specifically test the multifidus though... if anyone does, I would love to know. So, in a nutshell, with these type of patients, I do a lot of cervical stabilization exs (local and global). I am not sure if this helps, but I hope it does.
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Re: cervical spine HNP - September 7, 2004 4:33:00 AM
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Shill
Posts: 1090
Joined: February 13, 2003
From: Madison WI USA
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Eam,
If you or one of your colleagues is familiar with a repeated movements approach, such as McKenzie or a variation thereof, please try to get this patient evaluated as to which motions cause centralization of symptoms. This has been shown to be a reliable means of showing favorable prognosis through conservative care, at least in the lumbar spine, and anecdotally in the cervical spine. Neural mobes will always be irritating, or at least the ULTT will be positive in folks with impinged nerve roots. It is not likely adhered, but compressed. Mechanically reducing the compression will help this. She may have a horrendous looking neck according to MRI, but it is highly unlikely that all levels of HNP are symptomatic. Nevertheless, repeatedly flexing and or sidebending away from the painful and weak side may actually be perpetuating the symptoms. Weakness improves in these situations very gradually, and this needs to be monitored weekly to every other week, as objectively as you can, to avoid missing a progressive weakness situation.
Now, if you do a repeated movements approach, it is likely to cause some pain during the motion, but provided it isnt causing peripheralization following the motion, and provided the patient has no increased pain after you finish, unless it is central pain accompanied by an improvement in the peripheral pain, this is actually a favorable sign. If you do a good job explaining this to the patient, she will understand that the pain during is NOT a sign of the fact that the movement is incorrect.
Good Luck
Steve
PS- Carolina PT: How can you see the multifidi?
_____________________________
Steve Hill PT
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Re: cervical spine HNP - September 7, 2004 11:44:00 AM
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Bournephysio
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From: Calgary
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"hyper-reflexic triceps reflex" How sure are you of this finding? This is a red flag that suggests an umn lesion. Have you tested cranial nerves, hoffman, babinski, clonus, other long tract signs (eg lower extremity reflexes). I'm assuming that the history is clear of red flags.
Doug
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Re: cervical spine HNP - September 7, 2004 6:12:00 PM
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eam
Posts: 290
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From: New York, NY 10028
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Thanks everybody so far for the replies.
Doug-Hyper-reflexic is probably not the correct term here-I was just trying to point out that the this reflex was greater on one side-I certainly would not label it clonus by any means. It is semantics-sorry for the misunderstanding. I will check them again next time I see her.
Shill-I had thought about repeated movements. She does not have any peripheralizarion of sx's at all but they cover a rather diffuse dermatomal area neck into supra -scapula. I will try them and post back.
Caroline-I am unsure as to what you mean about multifidus. Maybe you can elaborate. Thanks!
Erica
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Re: cervical spine HNP - September 8, 2004 9:22:00 AM
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FLAOrthoPT
Posts: 1011
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From: West Palm Beach
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try going with stabilization exercises, supine into a blood pressure cuff sub-maximal, isometrics all planes, light rhythmic stabilizations, mulligan mwm: try blocking one segment below...is there any specific point where the pain goes to with fb, bb?
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Re: cervical spine HNP - September 8, 2004 9:54:00 AM
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Shill
Posts: 1090
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From: Madison WI USA
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Eam,
the pain referral into the periscapular or suprascapular area is, in fact, peripheralization. It doesnt have to follow a strict dermatomal pattern. This may also be a semantics issue, but if you think about centralization at a very detailed level, anything that is not directly on the midline is peripheralization. This may seem like nitpicking, but have her rate the size of the area of pain before and after the repeated movements, as well as the intensity, of course. IF the size of the area reduces, this is also centralization. Looking at it this way can help you stick with a plan that works, even if it doesnt give you immediate reduction and pure centralization to the central spine.
_____________________________
Steve Hill PT
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Re: cervical spine HNP - September 8, 2004 10:07:00 AM
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spfister
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HI,
There are several things here that "worry" me. HA (intermittent), Myotomal weakness (R) c5/6 with a hyper-reflexic triceps reflex on the right (what about biceps reflex, no significant mm guarding, (Paivm) and PIVM and nothing jumped out as being abnormal, normal SB and ROT.
1st off I would not be moblilizing this patient. There is absolutely nothing in what you have given us that indicates that is needed, and your lack of success with it should tell us to stop. Get some good self-reported scores (neck disability index or other) and possibly fear avoidance score to help you identify progress, or lack there of. Most likely your ROM and HA measures will fluctuate too much.
I would emphasize suboccipital release (I would assume tightness is found even though you said no spasm), Repeated movement if it helps (remember scapular pain is peripheralized pain), a lot of the stabilization exercises (make sure to strengthen the flexors, they have been shown to be weak in these patients and good results with strengthening. Research by Jull. Look at a synopsis at http://www.aptei.com/library/viewReport.jsp?report=168 and http://www.aptei.com/library/viewReport.jsp?report=138 Not my site, but a great resource)and trial of gentle mechanical traction with close monitoring of symptoms to make sure patient is not guarding or worsening.
_____________________________
Steve
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Re: cervical spine HNP - September 8, 2004 12:38:00 PM
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FLAOrthoPT
Posts: 1011
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From: West Palm Beach
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curious why you would traction if you are trying to stabilize, and why you would traction if you are saying avoid mobs? I discount DTR testing because it is only as reliable as the other side. I think it ineeds to be exaggerated difference either hypo or hyper to really see a difference, so I just discounted that, but if it is really hyper then that should be worrisome. However, could a facilitated segment cause hyper tonicity?
Go NSU!
Ben Galin, MPT, OCS
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Re: cervical spine HNP - September 8, 2004 6:04:00 PM
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Jon Newman
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From: Amherst, WI
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eam,
What type of collar is she wearing at night and why is she wearing it?
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: cervical spine HNP - September 8, 2004 6:14:00 PM
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FLAOrthoPT
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From: West Palm Beach
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i was guessing because she had lig. damage seen in flexion and ext x-rays then a soft collar not a bad idea for the first 6-8 weeks some times alar lig. damage or something, possibly only way she can sleep without impingement of her nerve root is keeping in spinal neutral with the collar at night, who knows....not unheard of, just don't like the psychosocial component it brings to elevate someone's perception of the magnitude of their injury...ok rambling now, i need to get some sleep
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Re: cervical spine HNP - September 8, 2004 6:42:00 PM
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eam
Posts: 290
Joined: February 5, 2004
From: New York, NY 10028
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Hi again-
I will be seeing the pt next week and I will post with status. However, I wanted to respond to some of the posters. Jon-She is wearing a soft collar at night b/c it is the only thing that allows her to sleep through. Any other thoughts?
Spfister-The PAIVM and the PIVM's were purely an evaluative procedure not a tx procedure.
I will check out the reference you mentioned, thank you.
Ben-you are absolutely correct about the central/peripher phenom- then indeed she does have peripheralization at times to her scapula. To answer your question, with FB and BB her sx's are to the right of midline (about 1 inch to the right of c3,c4)not into the scapula.
Thanks everyone!
Erica
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Re: cervical spine HNP - September 8, 2004 7:06:00 PM
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PTstud
Posts: 86
Joined: March 8, 2002
From: Texas
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Hello,
It sounds like your patient is suffering from various kyphotic kinks---when there is an acute disc injury and causes the discs to swell, when swelling subsides, the c-spine vertebrae come down mis-aligned. The superior uncovertebral jts come down more anterior to the caudal ones, significantly reducing fb ROM. To correct this, do the "technique according to Jenkner".
Sit pt on chair with you standing next to him. reach around his head and cradle it so that the little finger rests over the cranial vertebra being treated.. With the other hand, place the web space over the spinous process of the segment being treated.
With the first hand, provide a slight axial separation and extension maintaining contact with the cranial vertebra while you give an anterior push on the caudal vertebrae (8-10 sec hold)with your other hand. Move up every segment and ALWAYS treat the caudal segment on the superior. If you need a copy of my notes on this, email me and I will provide you with it. Hope this helps...
PS, Kyphotic kinks normally show up on xray.
MT, SPT
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Re: cervical spine HNP - September 8, 2004 10:11:00 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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sounds like pain is more at the facet region probably due to inflammatory process impinging nerve root now causing guarding away from that motion, and has kind of become global because she has petterned this for so long now. Has she/is she on any strong anti-inflammatories? MEdrol dose pack in the beginning and perhaps some high dose of ibuprofren now? I have a recurring instability in c7/t1 that presents similarly, and I am just too stubborn to heed my own advice and stabilize the area. I usually get it from sleeping funny or golfing occasionally. Anyway some high doses of advil for a day or two while I have some friends perform some mulligan type maneuvers and pain all gone. However, since this girl has been dealing with it for some time now, and has the brace to validate her pain, this is going to need some massive confidence and placebo effect going on, but since she is PT trained you are going to have to trick her some. Say, I have this one technique I want to try that works every time, and get in there block the segment below at the side of the spin. process and manually move the superior s/p superior a bit and aid it in the same direction as she rotates oppposite of where you are blocking in a sitting position to encourage the right proprios to be firing. If this increases pain, the switch up and block on opposite side etc etc. Usually works for me, you're going to need to do some soft tissue work her upper traps and lev scap must be just permamantly firing as she is guarding for this long, release her SCM, lev scap, upper traps with some MFR, MFR with movement, and get going on some spinal stabilization, scap retraction in front of a mirror to discourage shoulder elevation, and eventually progress into PRE cervical and shoulder, in functional patterns. These always take longer because the patient gets some bad behavioral patterns from guarding, pain patterns. Too bad we cannot get them like day 1 or 2 out of the injury! I would def. ween her out of that neck brace it is only adding to her guarding. Good luck,
Ben MPT, OCS
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Re: cervical spine HNP - September 9, 2004 3:33:00 AM
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Jon Newman
Posts: 1706
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From: Amherst, WI
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Hi eam,
I can presume that she is safe to be out of her collar since she only wears it at night. How does she feel with it off during the day time? Is she still figuratively wearing the collar?
We know that movement can help relieve her pain from your first post. Does she get any relief whatsoever with anti-inflammatory medication alone?
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: cervical spine HNP - September 9, 2004 5:09:00 AM
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spfister
Posts: 23
Joined: September 7, 2003
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Ah young Luke, I mean Ben, do you doubt the master. (sorry folks)
Ok, I like to use light mechanical traction because it can relax the muscles and at best I will get a mild graded distraction of the joints that may activate the mechano-receptors and possibly calm down the irritation. My dispute with much of the mobilization talked about here is that they all seem to be directed towards increasing movement, and her movement pattern does not indicate a joint dysfunction pattern. I guess if you would like to oscillate that would make me more open to the idea, but mechanical traction can be more efficient and you can get a longer treatment time. I think I agree with what Jon is getting at, if she can make it through the day without the brace, take it off at night as well. She is dangerously approaching the point of no return (psychosocial aspects, learned postures and movement patterns, and weakening stabilizers). I would focus on a gradual increase in exercise and activity, try some aerobic stuff with good posture. Just be careful, because if you make her too much worse you will lose her faith. Encourage, direct, and try to tell her that maintaining her level of pain/discomfort while increasing her activity is a positive thing.
My two cents.
Steve
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Steve
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Re: cervical spine HNP - September 9, 2004 5:46:00 AM
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chiroortho
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Couple of questions...MRI showed multilevel 'protrusions'...were they actually HNP, which would be very unlikely at 5 levels, or the proverbial 'bulging' discs?
FlOrthoPT mentions F/E xrays showing lig instability but I couldn't find any comments about xray findings. PTstud mentions 'kyphotic kinks', and if this means kyphotic angulation on the lat cerv view then this is strongly suggestive of posterior lig instability. Again, would like to hear more about the xrays.
'Hyperactive' tricep reflex and C5/6 weakness in isolation don't worry me much.
Sounds to me like she may be ready for some gentle SMT. Don't know much about PT techniques, but would be very careful and hold off till posterior lig instability is R/O.
Wish I had more info...
_____________________________
Greg Priest, DC, DABCO
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Re: cervical spine HNP - September 9, 2004 6:09:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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I would have to agree with Greg on this one. Rule out any contraindications with the X-ray/MRI and maybe try some SMT.
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Alex Brenner, PT, MPT, OCS
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Re: cervical spine HNP - September 9, 2004 9:10:00 AM
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manualtherapist
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From: Metuchen, NJ
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I agree with some sort of imaging. I also would suggest to continue with the suboccipital release and adding some OA & AO mobs (more specifically posterior condylar glides on C1, concentrated more to the R) w/ or w/o muscle energy. Definitely clear out the thoracic spine first (FRS & ERS from seatbelt?) and try some pivot prone w/ gentle chin tucks.
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Re: cervical spine HNP - September 9, 2004 9:28:00 AM
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rolf-inge
Posts: 23
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From: norway
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Hi EAM!
What do you mean with s/p mva work related?
Sorry asking but my first language is noT english!
MVA motor v.accident?What happened?I need some more before judging her clinical findings!
RIN
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RIN
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