cervical spine help with a patient (Full Version)

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blast7 -> cervical spine help with a patient (June 6, 2008 10:14:55 PM)

Patient is a middle aged woman who has a history of insidious onset right shoulder pain located at primarily right lateral delt and lateral upper arm.  Described as burning and stabbing. Had a cortisone injection 2 months ago with some short term relief but pain worsening again. She works at a factory repetitive movment with bilateral cervical rotation.  SHe states that while working she really does not have pain but at the end of the day once work has ceased it is quite bad. 

Cervical ROM WNL except 25% loss in bilteral side bending.  Right side bending and right rotation dramatically increase right shoulder pain.  Repeated cervical retraction increase pain to cubital fossa. Weakness noted of triceps 3+/5 and supraspinatus 4/5. Normal shoulder ROM.  DTR's 2 bilateral C5-7. Tenderness to palpation over lateral delt/lateral arm as well as right paraspinals.  Intermittent numbness along anterior forearm and inner upper arm. Negative spurlings and distraction.  Weakness noted with repeated dynamometer testing: 75lbs, 65 lbs, 55lbs.  The left UE was 60, 60, 60.  Also if I had the patient right side bend and test the right hand then it was 40,40,40lbs. 

Now overall there is a radiculopathy but what suprises me is the negative distraction, spurlings, and subjective report that pain is fine while working.  I'm relatively new to the outpatient setting so I need your help.  What do you think? Possible disc?

EDIT: X-RAY from 2 years ago c-spine AP and lateral views=degenerative disc changes c6-7.



Kaden -> RE: cervical spine help with a patient (June 7, 2008 12:41:26 AM)

I'll start with a couple of things but hope others will jump in the mix.

Doubt a disc or at least a true herniation can be blamed in someone above 30 years old, IMO. 

Is the weakness you describe fatigauble?

What do ULTT look like?

I have seen spurlings be negative in cases like these especially were repetitive movment can take a while to "fire" up the nerve and cause symptoms.  Usually this end of day pain can be the result of continued iritation and now inflammation that results in pain at the end of the day. 

Teach her self traction and a Spurlings type maneuver to try at the end of the day when symptoms are increased and have her tell you what these positions do to symptoms.

Obviously there is some mid C-spine facet dysfunction as seen with loss of SB.  Rotation being normal can be seen in this case b/c the TS and AA joint can compensate for any loss here but more difficult to compensate for a loss of SB.

My thoughts and this is just an educated guess based on what I here to this point.  Lower CS radiculopathy between C6/7 based on anatomy of were the C7 root exits (the triceps weakness is more unsual.  I am assuming at this point the supraspinatus weakness is not all that significant as this is seen in many middle aged) with decreased mobility in the mid cervical spine contributing to lack of equally disperced forced through the spine, some hinging at the C6/7 and the subsequent flare at the end of the day.

I would try some mobs to the mid cervical spine, maybe traction depending on her report to self gap/traction, check ULTT, posture education and possibly alter her job if possible to avoid excessive right rotation and see if symptoms change.

Sorry for the long resposne, but just some thoughts.  Interested to see what others are thinking.



blast7 -> RE: cervical spine help with a patient (June 7, 2008 8:57:56 AM)

Thanks for the response no matter how long.  ULTT's were all negative.  I had her go home using performing a neck extensor stretch primarily for occipitals as she as a protracted forward head position with very strong neck flexors.  I also instructed her to avoid right rotation as well as right side bending especially while at work. 

As far as the weakness, I should clarify that I believe this is more fatigueability and this actually is her primary complaint as it affects her productivity at work.  Her productivity has decreased because her arm feels "heavy" and this is what has finally brought her in to seek P.T.



cwagon -> RE: cervical spine help with a patient (June 7, 2008 9:59:44 AM)

Blast - I would suggest to continue your screen by retesting your strength patterns with the packed scapulae position - this position is maximal retraction and downward rotation of the scapulae.  In order to do this, the person must show maximal thoracic rotation.  We can start to cull out maybe some things that your patient's body is not telling her or you.



PTupdate.com -> RE: cervical spine help with a patient (June 8, 2008 10:09:50 PM)

Kaden pretty much covers all bases, and I'd add extra mobilization of her C5-6-7 segments to the left while in extension, or at least starting in neutral.   I have had this same problem myself, and never had trouble at work, yet the 4 mile ride home could be agonizing.....it's all in mechanical position and encroachment, which is something we can correct.



Shill -> RE: cervical spine help with a patient (June 9, 2008 12:34:45 PM)

My two cents would be that these things are often related to a disc-osteophyte complex, and are treated with mechanical treatments, repeated movements into retraction and extension, and/or side bending, whichever centralizes symptoms.  Throw in posture retraining as needed to reduce symptomatic activities, manual therapy as needed for whatever is found to be "needed" or to allow for greater comfort during therapy/exercises.  If you find an exercise that controls symptoms and/or centralizes, have them do it a million times a day.  OK, maybe not a million, but a lot. 

For fun and excitement, have her try to retract the neck then at the O-A, as that could intensify the pain to the cubital fossa.  I think you alude to this, but is the cubital worsening during, or as a result of the movement.   The during stuff is not often pleasant, but can lead to the centralization or at least reduction over time.



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