Outcomes Following the Addition of Thoracic Thrust Manipulation to a Multimodal Approach for a Patient with Chronic Mechanical Neck Pain: A Case Study

Transcription

1 Outcomes Following the Addition of Thoracic Thrust Manipulation to a Multimodal Approach for a Patient with Chronic Mechanical Neck Pain: A Case Study A case report submitted for the degree of Doctor of Physical Therapy at Carroll University Waukesha, WI Charise Kelm, SPT Spring 2009

2 Outcomes Following the Addition of Thoracic Thrust Manipulation to a Multimodal Approach for a Patient with Chronic Mechanical Neck Pain: A Case Study Charise Kelm, SPT, Mark Erickson, PT, MA, OCS, Elizabeth Muellenbach, MPT INTRODUCTION Neck pain is a common disorder encountered in the physical therapy setting that affects approximately 54.2% of adults. 1 Chronic neck pain typically results in functional limitations and disability that not only impact a patient s quality of life but also generate considerable economic burden. 2,3,4 While physical therapy management has been supported as a cost effective means for managing patients with chronic cervical pain, the changing nature of health care reimbursement challenges researchers to investigate the most efficiently effective means of patient management. 5,6 A comprehensive literature search revealed a broad scope of research on physical therapy management for mechanical neck pain with recent evidence supporting the use of thoracic thrust manipulation for patients with acute neck pain ( 30 days). 7,8 Little evidence is available on thoracic manipulation for patients with chronic cervical symptoms. The American Physical Therapy Association (APTA) has published updated clinical practice guidelines for the management of patients with neck pain, which support a variety of interventions including thoracic thrust manipulation. Much of the available research evaluates effectiveness of single interventions or paired intervention combinations. Few studies assess larger intervention combinations, which more closely match clinical practice, and no studies assess intervention combinations based on the newly revised clinical practice guidelines for patients with neck pain. 9,10 The purpose of this case study was to assess outcomes following the addition of thoracic thrust manipulation to multimodal physical therapy management for a patient with chronic mechanical neck pain.

3 PATIENT HISTORY / REVIEW OF SYSTEMS The patient was a 58 year old male referred to physical therapy in January 2009 with medical diagnoses of muscular low back pain (LBP), muscular cervical neck pain, and left upper quadrant muscular abdominal wall strain. He led a sedentary lifestyle and was employed as a print machine operator in which he was required to stand and sit throughout the day. His medical history (Table 1) included type II diabetes and thoracic spondylosis. The patient reported progressive loss of neck motion over the past six and a half months and an increase in mid back and neck pain. He also stated increasing difficulty with looking side to side and upward, sleeping, transferring from sit to stand, rolling, sitting or standing for prolonged periods, and bending. At initial examination, the patient s mid back pain was his worst symptom followed by neck pain. The mid-back pain resolved with conservative physical therapy, and at visit three the patient s primary complaint became neck pain. The patient reported chronic LBP and bilateral chest pain as additional concerns which were not the primary focus of this course of therapy. All general medical systems screening questions (Table 2) were negative with the exception of chest pain. The patient reported that his chest pain began after he fell out of bed and hit his back on a nightstand. The patient had been taking an anti-inflammatory medication for his mid back pain that was prescribed by his primary care physician. No previous therapeutic interventions had been provided for the patient s neck and mid back pain and no concurrent therapies were being implemented. Clinical Impression: The patient appeared to be an appropriate candidate for both physical therapy intervention and involvement in this case study because his medical history and subjective report indicated a musculoskeletal source of symptoms and he was

4 receptive to the use of spinal manipulation, performed by a student physical therapist, as an element of his care. Additional assessment was needed to further confirm a musculoskeletal source of symptoms and to identify relevant impairments and contributing factors to determine the patient s appropriateness for a multimodal course of physical therapy including thoracic thrust manipulation. EXAMINATION Observation / Palpation The patient required the use of both arms to transfer from sit to stand. He also required minimal assist to roll and transfer from supine to sit due to his mid back and chest pain. He ambulated without an assistive device, but reported limited standing and walking tolerance of minutes. Observation revealed pronounced left thoracic paraspinal musculature from T6-T12 that was tender to gentle palpation. Pain was reproduced and numerous trigger points were identified with palpation of the suboccipital, upper trapezius, cervical paraspinal, and scalene musculature bilaterally. The patient presented with guarded cervical spine movement in all directions, compensating with excessive visual tracking. Pain Intensity / Level Prior to the examination, the patient completed a body diagram for pain. (Figure 1). A 0-10 numeric pain intensity scale was used to quantify the patient s best (1-2/10), current (5/10), worst (10/10), and average (4.5-5/10) pain levels. The left side of the scale (0) was defined as no pain while the right side (10) was defined as worst possible pain. This instrument was chosen because it has been found to have high reliability

5 (0.95) and validity for assessment of pain in older adults. 11 Pain level was assessed at each session (Table 3). ROM Thoracic and lumbar active range of motion (AROM) (Table 4) approximations were made based on the therapist s visual assessment at visits one and ten. AROM of the thoracic and lumbar spine were not quantified with standardized procedures because they were not a primary focus area for our interventions. Cervical AROM (Table 5) was measured using the CROM instrument * (Figure 2). This device was chosen because it is supported as a reliable ( ) and valid means of assessing cervical range of motion (ROM) in patients with neck pain, with minimal detectable change ranging from , 13, 14, 15 CROM was measured at visits three and ten. Posture Posture was assessed with the CROM device, according to the manufacturer s procedures for quantification of forward head position and scapular protraction. (Table 6). All measures were performed with the patient sitting in a straight back chair with sacrum against the back of the chair, thoracic spine away from the chair, feet flat on the floor, and arms resting at his sides. Scapular protraction was measured from the spinous process at the intersection of a line connecting the inferior angles of both scapulae to the postero-lateral border of each acromion. The CROM device was chosen because it has been found to have high intertester reliability (ICC = 0.93) for the assessment of forward head posture in patients with neck pain. 16 Postural assessment measures were taken at visits 3 and 10. * Performance Attainment Associates 3600 Labore Road, Suite 6 St. Paul, MN

6 Strength / Endurance Isometric cervical strength was assessed with a hand held dynamometer, using the 1.5 molded plastic stirrup. Flexion, extension, side-bending, and rotation isometric strength measures were taken with the patient in the same position utilized for cervical ROM assessments. Dynamometer placement is described in (Table 7). The patient was instructed to push as hard as he could against the stationary plastic stirrup in each tested direction using only his neck musculature. While this method of assessing cervical strength has not been validated, it is similar to the methods used by Vernon et al. 17 and Cagnie et al. 18 in their assessments of isometric cervical muscle strength with a modified sphygmomanometer and Biodex isokinetic dynamometers respectively which have been shown to have good reliability (r = ) and validity for the assessment of cervical 17, 18 strength in patients with neck pain. Isometric cervical strength was assessed at visits 3, 7, and 10. (Table 8). Deep cervical flexor isometric endurance was assessed using the craniocervical flexion test 19 with a pressure biofeedback stabilizer (Figure 3). Chiu, Law, and Chiu assessed this device on patients with and without chronic neck pain and reported good reliability (r = 0.72.) and validity for the assessment of deep cervical flexor control. 20 Deep cervical flexor isometric endurance was assessed at sessions 3,6,8,9, and 10. (Table 9) Joint Mobility Posterior to anterior (PA) joint play assessments were performed on the thoracic and lumbar spine per the APTA s updated neck pain clinical practice recommendations. 8 Lafayette Instrument Co. Europe 4 Park Road Sileby, Loughborough, Leics., LE12 7TJ. UK Chattanooga Group 4717 Adams Road Hixson, TN

7 Hypomobility was noted at levels T3-L2 and regional pain was reported with PA joint glides at T1-T6, L4, and L5. Cervical joint mobility was not assessed at the initial visit secondary to the patient s cervical spine hypersensitivity to touch. Neurological Screen Cervical spine myotome, dermatome, and deep tendon reflex testing were all negative for central nervous system pathology. Flexibility Lower extremity hamstring flexibility was assessed using the supine straight leg raising test which was positive bilaterally for hamstring shortness. 21 Scalene and upper trapezius flexibility were assessed with passive ROM into a maximally lengthened position. Both muscle groups were short bilaterally. Upper Limb Tension Testing Adverse mechanical neural tension (AMNT) testing was performed as described by Butler and Magee and was positive for radial and median nerves bilaterally with greater patient reported symptoms on the right compared to the left. 8, 21, 22 No AMNT was identified in the ulnar nerves for either upper extremity. Other Transverse ligament integrity was assessed with the Sharp Pursor test and was negative, indicating an intact transverse ligament. 21 The patient was screened for vertebrobasilar insufficiency with the vertebral artery test (VAT) which was negative suggesting uncompromised vertebral artery structure. 21 The validity (sensitivity 0%, specificity 67-90%, positive predictive value 0%, negative predictive value 63%-97%) of

8 the VAT is not been well supported so it was difficult to rule out the possibility of 23, 24 vertebrobasilar insufficiency. EVALUATION / DIAGNOSIS / PROGNOSIS / PLAN OF CARE Evaluation The patient presented with signs and symptoms consistent with mechanical back and neck pain including the impairments listed in table 10. The patient s impairments limited his ability to sleep through the night, transfer from sit to stand and sit to supine, bend, kneel, squat, lift, roll, walk for longer than minutes, and sit or stand for longer than 30 minutes. Diagnosis: Following the Guide to Physical Therapist Practice 25 the patient s Preferred Physical Therapist Practice Patterns were 4B: Impaired Posture and 4C: Impaired Muscle Performance. Prognosis A six week course of therapy at a frequency of two visits per week was determined appropriate for this patient based on the Guide to Physical Therapist Practice s 25 recommendations for patients in practice patterns 4B and 4C. Six weeks of intervention were projected rather than four weeks secondary to the patient s comorbidities of diabetes which could slow healing time and low back and chest pain which could contribute to higher levels of overall pain and functional limitation. The patient had good potential to attain his goals of decreasing mid back and neck pain, increasing back and neck ROM, decreasing AMNT, and increasing standing and sitting tolerance for improved ability to complete ADLs and IADLs and return to his premorbid activity level at work, home, and within the community. The patient s rehabilitation

9 potential was good to attain the goals as a result of his intact cognitive status, stated willingness to participate in self management, and no history of neck and mid-back pain. Plan of Care The intervention program was scheduled two times each week for the first four weeks and was decreased to once a week for the last two weeks. Interventions consisted of thoracic thrust mobilization and manipulation, therapeutic exercise, posture education, strength training, soft tissue mobilization (STM), neural mobilization, stretching, manual traction, and patient education. Clinical Impression The examination findings support the patient s appropriateness for physical therapy intervention and as a subject for this case study in the following ways: His pain was reproducible, he presented with signs and symptoms consistent with mechanical neck pain of musculoskeletal origin, and he had limited thoracic spine mobility which suggested that thoracic thrust manipulation may be an important contributing factor to his cervical pain. We hypothesize that the following outcomes will be observed: decreased cervical pain, increased cervical and thoracic spine mobility, decreased upper limb neural tension, normalized muscle tone and length, and improved posture. INTERVENTION Following examination, treatment interventions were prescribed and implemented for ten, 45 minute sessions over six weeks. Visit frequency was decreased from twice to once a week for the last two weeks secondary to the patient s improvement and to accommodate his schedule. Interventions included mobilization, manipulation, stretching, strengthening; STM, ultrasound, trigger point sustained pressure, neural mobilization,

10 breathing exercises, posture education, and a progressive home exercise program (HEP). (Table 11) Interventions were selected based on the APTA s updated neck pain clinical practice guidelines 26, equipment availability, patient tolerance to interventions based on pain level and positional tolerance, and potential of the interventions to address the relevant impairments and functional limitations. Implementation of several interventions deviated from the APTA s clinical practice guidelines to best meet the patient s needs and in response to his clinical presentation. Mechanical cervical traction was not utilized because of the patient s heightened suboccipital muscle sensitivity and poor tolerance for cervical traction device placement. Manual traction was utilized in place of mechanical cervical traction. Cervical manipulation was not performed for several reasons. First, cervical manipulation is not an entry level physical therapy skill and could not be legally or ethically performed by the student physical therapist was providing 90% of all interventions. Second, the subject did not meet the prediction criteria for one who would benefit from cervical manipulation. 8 Ultrasound was not included in the APTA s practice recommendations, but was utilized as an adjunctive intervention prior to soft tissue mobilization to increase tissue temperature and pliability. Our hypothesis was that this combination of interventions would improve strength and mobility and decrease pain for improved function. All interventions, except for those provided on visit five, were performed by a student physical therapist under the supervision of a licensed practicing physical therapist. Interventions performed at visit five were provided by the licensed supervising therapist.

11 Interventions provided at each session are presented in Table 12. Sessions one and two were targeted at addressing the patient s mid-back pain as this was his primary concern at the time. Session three was the beginning of the patient s enrollment into the formal case study as his primary complaint changed to cervical pain. All therapy sessions during the patient s enrollment in the case study included either thoracic spine mobilization or manipulation. Thoracic spine mobilization was utilized in the beginning of the study due to the patient s intolerance to manipulation at that point in time. Mobilization grades were progressed throughout the course of treatment until the patient was able to tolerate thrust manipulation. All mobilizations and manipulations were performed with the patient in prone. Mobilizations of grades I-IV were performed with a PA force applied to the spinous process of each targeted segment with two oscillations/second for 30 seconds at each segment. Grade V mobilizations, or thrust manipulations, were performed with a single posterior to anterior force applied to the transverse processes of each targeted segment with fast velocity and small amplitude. Ultrasound was applied at a continuous setting, at1mhz for upper trapezius and thoracic paraspinals and 3 MHz for cervical paraspinals, at a W/cm2 intensity, and for a treatment time of approximately 8-10 minutes. Ultrasound parameters were set to attain a three degree tissue temperature increase to maximize pliability for subsequent STM based on Draper, Castel, and Castel s study on rate of temperature increase with 1MHz and 3 MHz continuous ultrasound. 27 Supine to sit transfer training was performed to educate the patient on back protection techniques. The patient was educated on the importance of good posture and

12 general physical activity to improve cervical spine alignment and general health respectively. The patient completed daily 20 minute walks during his enrollment in the case study which were performed as an adjunct to his physical therapy home exercise program. Soft tissue mobilization was a combination of efflurage and pettrisage based on the patient s pain level and STM tolerance. Cervical isometrics were performed with the patient in sitting with resistance generated for ten, five second hold repetitions. Stretching was performed in two sets of 30 second increments for each targeted muscle group. Deep cervical endurance training was performed with a pressure biofeedback cuff at the maximal amount of pressure that the patient could attain with the least accessory muscle use. The patient was instructed to hold ten repetitions for ten seconds each. Nerve mobilization was performed utilizing a flossing technique. The patient s HEP included the exercises and stretches noted in table 12. He was instructed to complete his entire HEP twice each day which he reported completing every day for the six weeks treatment duration. The HEP supplemented therapy by improving muscle strength, endurance, and length; neural mobility; and habitual posture to address the underlying causes of certain impairments between each clinic session. HEP technique was evaluated and corrected at each session. OUTCOMES Prior to the examination, the patient completed the Modified Oswestry Low Back Pain Questionnaire (OSW) (Table 13). Prior to visit number three, he completed the Neck Disability Index (NDI) (Table 14), the Northwick Park Neck Pain Questionnaire (NPNPQ) (Table 15), and the Patient Specific Functional Scale (PSFS) in reference to his

13 neck pain (Table 16). All outcome measures were repeated at the final treatment session and the PSFS was repeated at a seven and a half week follow up. The OSW is a ten item scaled assessment tool that assesses the impact of LBP on activities of daily living and disability. Fritz and Irrgang reported good reliability (0.90) and validity of the OSW to assess disability resulting from acute work related LBP. 28 They also reported a minimum clinically important change (MCIC) of 6 points (sensitivity = 91%, specificity = 83%). The NDI is a 10 item modified version of the OSW designed to assess self rated disability in patients with neck pain. Vernon reported strong reliability (r = 0.89) and validity of the NDI for the assessment of disability related to neck pain. 29 He also reported a MCIC of 3-5 points. The PSFS is a ten point scale designed to assess patient reported disability in subjects with neck pain. Westaway, Stratford, and Binkley reported good reliability (0.92), validity (r = ), and sensitivity to change (r = ) for disability determination related to subjective functional task performance. 30 Patient reported percentage of normal function was collected as an additional subjective assessment of functional ability with consideration of all ADLs and IADLs. The patient was asked to report his current percentage of normal/full function with 100% defined as full ability to complete ADLs and IADLs at pre-injury level. Percentage of normal function was assessed at visits 1, 8, 10, and at the 7.5 week follow-up. (Table 17). Patient reported pain level, cervical AROM, deep cervical flexor endurance, and cervical strength were additional outcomes compared at baseline. Patient reported pain level was also assessed at the seven and a half week follow-up.

14 Comparisons between pre and post test outcome measures revealed the following: a 12 point decrease on the OSW from 16/50 to 5/50 with a percent decrease from 32% to 10% with a disability level decrease from moderate to minimal; a 12 point decrease on the NDI from 17/50 to 5/50 with a percent disability decrease from 34% to 10%; a 7/36 point decrease on the NPNPQ from 14/36 to 7/36 with a percent disability decrease from 38.8% to 19.4%; increases in patient specific functional scale scores from 2/10 to 10/10 for all three functional activities (Table 16); an increase in reported percentage of normal function from 5% to 95-97%; a decrease in back pain from 5/10 to 0/10; a decrease in neck pain from 5/10 to 1-2/10; increases in cervical AROM as follows: flexion 9 degrees, extension 7 degrees, left and right rotation 11 degrees each, left lateral flexion 10 degrees, and right lateral flexion 13 degrees; an increase in cervical muscle strength as follows: flexion increased by 2.8# (50% increase), extension increased by 4.5# ( 48% increase), right lateral flexion increased by 2.9# ( 37% increase), left lateral flexion increased by 2.7# (40% increase), right rotation increased by 1.7# (19% increase), and left rotation increased by 0.3# (4% increase); and improvements in deep cervical flexor endurance measures from 2, 2 second holds on visit three to 10, 10 second holds on visit 10. DISCUSSION Literature supports thoracic spine hypomobility as a probable underlying cause and potential contributing factor to mechanical neck pain. 31 A recently published randomized controlled trial reported that the use of thoracic thrust manipulation in combination with electrothermal therapy resulted in reduced pain, improved mobility, and decreased disability for forty-five patients with acute mechanical neck pain. While

15 these results support the use of thoracic thrust manipulation for patients with acute cervical pain, they cannot be generalized for patients with chronic mechanical neck pain. Based on anatomical relationships, it is reasonable to consider the impact of thoracic spine hypomobility on cervical spine mechanics and pain may be similar for patients with both acute and chronic mechanical neck pain. Few studies assess outcomes of intervention combinations of greater than two or three, and no studies assess combinations of interventions based on the newly revised neck pain clinical practice guidelines. 9,10 Assessment of larger intervention combinations is important for generalizability to traditional clinical practice as physical therapy clinicians rarely utilize only two or three interventions throughout the course of a patient s care. This case report attempted to expand investigation of thoracic thrust manipulation for patients with cervical pain by examining outcomes following the use of thoracic thrust manipulation and a multimodal group of interventions based on the APTA s clinical practice guidelines. Additionally, the authors sought to examine results following the implementation of this multimodal approach for a patient with chronic cervical pain as there is little evidence on the use of thoracic thrust manipulation for patients with symptoms past thirty days. Change in cervical AROM measures from initial to final treatments were similar to those reported by Gonzalez-Iglesias et al, who assessed thoracic thrust manipulation for patients with acute neck pain, which suggests that this intervention may be appropriate for patients with chronic cervical pain. Rotation and side bending AROM changes all surpassed the minimal detectable change º which suggests that the improvements were true changes. Flexion and extension AROM changes fell within the

16 range which could be representative of true change, but introduces the possibility that the changes were due to measurement error. Long term follow up studies would be beneficial to determine if patients maintain cervical AROM improvements. Changes in disability level measured by the Northwick Park Neck Pain Questionnaire were also similar to Gonzalez-Iglesias study further supporting the efficacy of thoracic thrust manipulation for patients with mechanical neck pain. Comparison of OSW and NDI scores from pre and post intervention revealed 11 and 12 point increases respectively which were nearly two and four times the minimum clinically important change respectively. These results support that the patient presented with clinically and functionally significant decreases in disability resulting from neck and back pain. Patient reported percentage of normal function for walking improved by 70% from visits three to ten and an additional 10% from visit ten to the seven and a half week follow up. This 80% improvement represented the patient s return to full, normal function. Patient reported percentage of normal function for sit to stand transfers and prolonged sitting improved by 80% from visits three to ten which also represented a return to full normal function. This 80% improvement was maintained at the seven and a half week follow up. The current study reports the longest follow up period to this point for functional activity level improvements which suggests that functional improvements obtained from the use of thoracic thrust manipulation combined with a multimodal intervention approach may continue beyond a one month and a half month follow up period. Future studies should investigate if the identified functional improvements persist at and beyond a 12 month follow up period.

17 The reported outcomes appear to be both clinically and functionally significant and should be considered in the management of patient s with chronic cervical pain. Based on case study design, the author is unable to determine cause and effect relationships therefore further research on the application of this combination of interventions on a larger patient population is warranted. The researchers propose that the multimodal combination of interventions applied may have been the most likely source of the patient s functional improvements as the chronicity of his symptoms, with little change over the six and a half months prior to physical therapy, diminishes the possibility that his improvements were due to time and the natural course of healing alone. There were several weaknesses of this study including the following: a small sample size which reduced the researcher s abilities to make cause and effect correlations, lack of researcher blinding which may have introduced testing bias, inclusion of an intervention (ultrasound) not spoken of in the APTA s clinical practice guidelines, and use of a strength assessment tool (hand held dynamometry) that has not yet been validated in patient s with neck pain. The outcomes following the use of thoracic thrust manipulation in combination with interventions from the APTA s clinical practice guidelines for the management of a patient with cervical pain support the hypothesis that this combination of interventions may be an effective approach for the management patients with chronic mechanical neck pain. Studies have shown that despite evidence supporting the benefits of thoracic thrust manipulations, many practicing therapists avoid or underutilize this intervention. 31 The positive outcomes following the implementation of thoracic thrust manipulation interventions provided by a student physical therapist who had received no more than

18 five total hours of classroom instruction in the technique suggest that it is an intervention that could be safely utilized by all practicing therapists. A recent study reported no specific level of manipulation training for the therapists conducting thrust manipulation with a more complicated technique than was employed in this study. 7 Therefore, the authors propose that the use of posterior to anterior thoracic thrust manipulation is a safe and appropriate intervention tool for the management of patients with chronic cervical pain and should be utilized by all practicing physical therapists as appropriate for optimal patient care. CONCLUSION Based on outcomes observed in this case report, the authors recommend the use of thoracic thrust manipulation in combination with interventions supported as best practice by the APTA s updated clinical practice guidelines for patients with neck pain. We suggest that thoracic thrust manipulation is a safe and appropriate intervention that should be considered by any practicing clinician for the management of patients with chronic mechanical neck pain.

19 TABLES Table 1: Demographics & Medical History Age 58 Gender Male Hand Dominance Right Ethnicity Caucasian Occupation Printer Medical Diagnoses Muscular low back pain Muscular cervical neck pain LUQ muscular abdominal wall strain Chief Complaints (in order of severity) mid back pain neck pain chest pain low back pain Past Medical history Restless leg syndrome Spondylosis of the thoracic spine Imaging / Special Tests Nuclear Treadmill Stress Test (-) Medications Amlodipine (Norvasc) Escitalopram (Lexapro) Fexofenadine (Allegra) Flucticasone Nasal (Flonase) Lisinopril Pioglitazone (Acos) Ropinirole (Requip) Aspirin Rosuvastatin Calcium (Crestor) Multivitamin Allergies Sudafed Smoker No Self Management None Previous PT None Family History Heart Disease Inclusion Criteria Neck pain of insidious onset Exclusion Criteria Spinal Instabilities, Smoking Table 2: General Systems Screen Questions Question Have you experienced any recent changes in bowel or bladder function? Have you experienced any recent episodes of dizziness or syncope? Have you experienced any nausea or vomiting? Have you experienced any recent chest pains? Have you experienced any numbness or tingling? Have you experienced any shortness of breath? Have you experienced any malaise / general feeling of being unwell? Response No No No Yes No No No Table 3: Patient Reported Pre & Post Intervention Pain Level Treatment Back Pain Neck Pain

20 Session (1-10/10) (1-10/10) Pre Treatment Post Treatment Pre Treatment Post Treatment following STM following supine to sit transfer / / Not assessed 6 2 at rest when moving or laughing Table 4: Thoracic and Lumbar Active Range of Motion Visit 1 (% of full ROM) Visit 10 (% of full ROM) Flexion 100% 100% Extension 75% * 100% Left Rotation 100% 100% Right Rotation 100% ** 100% Left Side bending 20%*** 80% Right Side bending 20% ** 80% * Minor mid back pain ** Moderate mid back pain *** Moderate mid back pain, left worse than R Table 5: Cervical Active Range of Motion Visit 3 Visit 7 Visit 10 Flexion 33 * Extension 35 * Left Rotation Right Rotation ** 60 Left Lateral Flexion ** 34 Right Lateral Flexion *Movement increases headache intensity ** Movement increases neck pain to 2/10

21 Table 6: Thoracic and Cervical Spine Posture. Visit 3 Visit 10 Left Rounded Shoulder 35.7 cm 35.0 cm Right Rounded Shoulder 36.2 cm 36.2 cm Forward Head Position 24.5 cm 20.0 cm Table 7: Hand Held Dynamometer Placement during Strength Testing Cervical Motion Hand Held Dynamometer Stirrup Placement Flexion Center of forehead Extension 2 cm above the occipital protuberance Lateral Flexion 2 cm centered above the earlobe Rotation Temporal line, 9 cm lateral to bride of nose, 3 cm superior to edge of eye Table 8: Cervical Muscle Strength Visit #3 Visit # 7 Visit # 10 Flexion 2.8# 2.3# 5.6# Extension 4.8 # 4.6# 9.3# Right Lateral Flexion 4.8# 5.7# 7.7# with 2/10 left neck pain Left Lateral Flexion 4.6# 5.4# 7.3# Right Rotation 7.1# 4.1# 8.8# With 1.5-2/10 left neck pain Left Rotation 7.7# 4.6# 8.0# Table 9: Deep Cervical Flexor Endurance Visit Hold time x Repetitions (seconds) Pressure (mm Hg) Visit #3 2 seconds x 2* 22 Visit # 6 10 seconds x seconds x 1* Visit # 8 10 seconds x Visit # 9 10 seconds x Visit # seconds x * further testing limited by neck pain and an increase in HA intensity. Table 10: Impairments identified at initial examination Impairment Description Pain Left thoracic spine Bilateral cervical spine Bilateral low back

22 Decreased Active ROM Decreased Joint Mobility AMNT Decreased muscle length / flexibility Trigger points Impaired Posture Weakness Poor Endurance Bilateral chest Lumbar, thoracic, and cervical spine Lumbar and thoracic spine Bilateral median and radial nerves Bilateral hamstrings, scalenes, and upper trapezius Bilateral scalenes, upper trapezius, and suboccipitals Forward head Bilaterally protracted shoulder girdles All cervical muscles Deep cervical flexors. Table 11: Interventions Intervention Location / Description Mobilization Thoracic spine Manipulation Thoracic spine Isometric Strength Training Cervical Stretching Scalenes, upper trapezius, pectoralis major & minor, and hamstrings Endurance Training Deep cervical flexor muscles Soft Tissue Mobilization Bilateral upper and middle trapezius, scalenes, suboccipitals, and cervical and thoracic paraspinals Ultrasound Prior to soft tissue mobilization Trigger point release Bilateral upper trapezius, scalene, and subocciptials Nerve Mobilization Radial & median Breathing exercises Lower respiratory breathing Posture education Verbal, tactile, written, demonstrative methods Progressive Home Exercise program Table 12: Weekly Interventions Week Visit Intervention 1 1 Initial Evaluation Ultrasound to L thoracic PS STM to L thoracic PS Sit supine transfer training 2 Ultrasound to L thoracic PS STM to L thoracic PS Cervical retraction / Posture re-education*

23 Chin tucks* 2 3 Additional therapeutic testing - Neck Disability Index - Northwick Park Neck Pain Questionnaire - Patient Specific Functional Scale - Spurling s Compression Test - Cervical AROM - Thoracic and cervical spine posture assessment - Cervical strength assessment - Deep cervical endurance assessment Ultrasound to L thoracic PS STM: bilateral thoracic and cervical PS, suboccipitals and scalenes Pectoralis stretch* Trigger point release: bilateral suboccipitals and scalenes Grade I & II thoracic and cervical spine mobilizations 4 Deep cervical endurance training Chin tucks / Posture Re-education Upper trapezius stretches* Cervical isometrics.* STM to bilateral thoracic & cervical PS, UT, scalenes, & suboccipitals Trigger point release to bilateral UT and suboccipitals Grade II P.A. joint mobilization to thoracic spine 3 5 Deep cervical endurance training Chin tucks Upper trapezius stretches Cervical isometrics.ps paraspinals and levator scapulae. STM to bilateral UT and cervical PS Grade II P.A. joint mobilizations to thoracic spine 6 Deep cervical endurance training Seated hamstring stretches* Median nerve mobilization* Seated trunk extension posture exercises* Ultrasound to bilateral cervical PS and suboccipitals. STM to bilateral UT, supraspinatus, rhomboids, cervical and thoracic PS, suboccipitals, & scalenes Trigger point release to bilateral UT Grade II & III P.A. joint mobilizations to thoracic spine 4 7 Ultrasound to L thoracic PS STM to L thoracic PS, bilateral UT, and bilateral scalenes. Trigger point release to bilateral UT and scalenes. Cervical retraction in sitting posture re-education Cat/Camel thoracic / lumbar stretch* Posture re-education Provided pt with handout for sitting ergonomics during desk work. Scalene & UT stretches Median nerve mobilization Grade IV P.A. joint mobilizations to thoracic spine 8 Ultrasound to cervical PS, suboccipitals, and UT. STM to bilateral UT, thoracic & cervical PS, levator scapulae, scalenes, and suboccipitals. Trigger point release to scalenes Deep cervical endurance training Median nerve mobilization

24 Grade V P.A. joint mobilizations/thrust manipulations to thoracic spine 5 9 STM to bilateral UT, thoracic & cervical PS, scalenes, rhomboids, and suboccipitals. Median nerve mobilization Radial nerve mobilization* Pectoralis stretch in doorway Deep cervical endurance training Posture re-education Grade V P.A. joint mobilizations/thrust manipulations to thoracic spine 6 10 STM to bilateral cervical PS, scalenes, levator scapulae, and suboccipitals. Trigger point release to bilateral scalenes and subocciptials Manual cervical distraction Deep cervical endurance training Pectoralis stretch Median and radial nerve mobilization Shoulder girdle retraction / posture re-education Cervical isometrics Scalene & UT stretches Grade V P.A. joint mobilizations/thrust manipulations to thoracic spine P.A. = posterior to anterior PS = paraspinals US = ultrasound UT = upper trapezius * = indicates exercises prescribed for the patient s home program and the visit on which each intervention was added to the home exercise program. Table 13: Pre & Post Intervention Modified Oswestry Low Back Pain Questionnaire Results Session 1 Session 8 Percent Disability 32% 10% Level of Disability Moderate Minimal Table 14: Pre & Post Intervention Neck Disability Index Results Session 3 Session 10 Total Score 17/50 5/50 Percent Disability 34% 10% Table 15: Pre & Post Intervention Northwick Park Neck Pain Questionnaire Results Session 3 Session 10 Total Score 14/36 7/36 Percent Disability 38.8% 19.4% Table 16: Pre & Post Intervention Patient Specific Functional Scale Results Activity Session 1 Session 3 Session 6 Session 7 Session 9 Session week follow-up

25 Walking Sit Stand Transfers Prolonged Sitting Table 17: Patient reported percentage of normal functional level Visit #1 Visit #8 Visit # week follow up Subjective Percentage of Normal Function 5% 65% 85-90% 95-97% FIGURES Figure 1: Body Diagram (Completed at Initial Examination)

26 Figure 2: CROM Instrument Figure 3: Pressure Biofeedback Cuff

27 Figure 4: Pre & Post Intervention % Disability Outcomes Percent Disability 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 32% 10% Oswestry Low Back Pain Questionnaire 34% 10% Neck Disability Index 38.80% 19.40% Northwick Park Neck Pain Questionnaire Pre Intervention Post Intervention Test Figure 5: Patient Specific Functional Scale Function (0-10) Walking Sit to Stand Transfers Prolonged Sitting week follow up Visit

28 Figure 6: Patient Reported % of Normal Function Percentage of Normal Function 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% % of Normal Function 0% Visit Figure 7: Pain Ratings Pain Score Neck Pain Back Pain week follow up Visit

29 Figure 8: Cervical Active ROM Measures Degrees Flexion Extension Left Rotation Right Rotation Left Lateral Flexion Right Lateral Flexion Visit 3 Visit 7 Visit 10 Motion Figure 9: Cervical Muscle Strength Force Generated (#) Flexion Extension Right Lateral Flexion Left Lateral Flexion Right Rotation Left Rotation Visit 3 Visit 7 Visit 10 Motion

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