Regional Review of Musculoskeletal System: Head, Neck, and Cervical Spine Presented by Michael L. Fink, PT, DSc, SCS, OCS Pre- Chapter Case Study

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1 Regional Review of Musculoskeletal System: Presented by Michael L. Fink, PT, DSc, SCS, OCS (20 minutes CEU Time) Subjective A 43-year-old male, reported a sudden onset of left-sided neck and upper extremity pain that began 5 days prior to his first visit to PT. He stated he awoke with moderate cervical pain that worsened through the morning and radiated to the left upper extremity. He could not identify any movement, posture, or activity that affected the intensity of his symptoms. His past medical history was significant for prior neck pain and radicular symptoms, which were effectively treated by medication approximately 1 year prior to this recent onset of pain. He was unsure of the side of symptom involvement with the previous occurrence. His medical history was otherwise unremarkable and he reported using no medications. The initial neck disability index (NDI), was 40%, indicating moderate disability. The patient rated his pain at 4/10 for least pain and 7/10 for worst pain in the previous 24 hours. 1

2 Objective Cervical spine AROM: forward flexion to 25, extension to 55, left and right lateral flexion to 26 and 58, respectively (measured with a gravity goniometer). Left cervical rotation was estimated to be limited by 40% compared to right rotation (visual assessment). All cervical motions increased the left upper extremity symptoms. Left thoracic rotation was minimally limited compared to right thoracic rotation (visually assessed during patient active trunk rotation while seated with the hands on the opposite shoulders). Brachioradialis deep tendon reflex was diminished (1+) on the left side as compared to the right side (2+). All the other deep tendon reflexes were deemed normal. Upper extremity manual muscle testing revealed 5/5 grades bilaterally, with 2 exceptions: biceps brachii and wrist extensors on the left side were graded 4/5. Passive intervertebral accessory movement of the cervical spine was tested with the patient in supine. Each vertebral segment was passively glided to both sides while assessing pain and limitation of movement. There was limitation of movement and left side tenderness at the C5/C6 level during right side glide. List the top diagnosis Treat, refer or treat and refer? Treatments Visit 1 High velocity, small-amplitude traction manipulation of the thoracic spine and then manipulation with traction and minimal rotation of the cervical spine. Indications for thoracic dysfunction were limited forward flexion, with increased in distal symptoms and decreased left thoracic rotation. High-velocity, small amplitude cervical manipulation was done with the goal of increasing the opening of the left intervertebral foramen between C5 and C6 in an attempt to release compression of the C6 spinal nerve on the left. 2

3 Cervical spine AROM was immediately reassessed after the manipulation techniques and was increased to 36 for flexion, 65 for extension, 55 for left lateral flexion, and near full left cervical rotation. Right lateral flexion and rotation were unchanged. Thoracic rotation was symmetrical. The patient reported decreased pain during the movements. Reassessment was followed with intermittent mechanical cervical traction. Traction was applied with the patient supine and the neck in approximately 25 of flexion (from the horizontal plane). Maximum pull was 25 lbs of force for 25 seconds and minimum pull was 7 lbs for 5 seconds. The patient tolerated the treatment without alteration of arm symptoms and reported decreased cervical spine pain. Visit 2 (3 days after the initial visit) MRI for the cervical spine ordered by the referring physician was performed between the first 2 visits. The report indicated C5-6 herniated disc, with an associated osteophyte causing moderate right neural foramina stenosis and left mild neural foramina, and central canal stenosis at that level. The patient reported some improvement in symptoms. He reported that he no longer had sharp pain below the elbow. Numeric pain rating scale rating was 3/10 for least pain and 7/10 for worst pain in the previous 24 hours. He reported aching pain and numbness of the hand now. NDI score was 48% at this visit. Cervical AROM was improved from 25 to 45 of flexion, extension was unchanged at 55, lateral flexion was symmetrical, and left rotation improved from 40% to approximately 25% deficit compared to right rotation. Left arm symptoms were increased with cervical spine flexion and right side flexion. Reflexes were noted to be equal bilaterally (2+). Manual muscle testing was not performed. After examination, thoracic and cervical manipulation and intermittent cervical traction were used, as performed during the first visit. No exercises were given to the patient but improving postural awareness while seated was discussed. How did the patient s pain, Cervical AROM, and NDI score change from the Initial Examination/Visit 1? 3

4 Does the MRI results correlate with the patient s symptoms? Visit 3 (1 week after the second visit) Cervical AROM was 35 for lateral flexion bilaterally, 35 for flexion, 58 for extension, and left rotation was limited by approximately 25% as compared to right rotation. Pain was rated at 3/10 at best and 7/10 at worst over the previous 24 hours. NDI = 36%. Manual muscle testing revealed 4/5 strength in the biceps brachii, shoulder external rotators, and wrist extensor muscles. At that time, the referring physician was contacted with the suggestion of performing electrodiagnostic testing. The test was deferred until 3 weeks after onset of symptoms. In the meantime, the patient was followed for 3 additional visits. How did the patient s pain, Cervical AROM, UE strength, and NDI score change from the Initial Examination/Visit 1 and Visit 2? Do you agree with the PT s recommendation for electrodiagnostic testing? Why or why not? Visits 4-6 Pain in the neck was rated 2/10 at worst over the previous 24 hours and the patient did not complain of upper extremity pain. Shoulder external rotation strength on the left side was graded 1/5 by manual muscle testing, with only 4

5 trace muscle activity noted by palpation. Otherwise, strength was noted to be normal throughout the left upper extremity, including the biceps brachii and wrist extensors. Brachioradialis reflex on the left was diminished (1+) compared to the right. How did the patient s pain, UE strength, and UE reflexes change from the Initial Examination/Visit 1, Visit 2, and Visit 3? What are you suspecting now? How do you proceed? Is this an emergent situation? Notes: 5