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Patient is a 53 y.o telephone technician with chief complaint of R sided neck pain following an MVA in May 2016. Patient was rearended while stopped, and then hit the car in front of him. Radiographs performed and negative. He was given pain medicine and muscle relaxers, but no other treatment performed thus far. Reports that his pain has improved since the accident, but has plateaued in the last month and his main complaint is difficulty turning his neck to the left. He denies any: parathesias, scapular, UE symptoms, dizziness, headaches, visual changes, or any other red flag signs/symptoms. His pain is isolated to the R side of his mid cervical spine. He reports some difficulty with prolonged positioning of his neck during work tasks ie. Working overhead, using his arms, driving turning his neck to the left.
Pain levels = 0-5/10
Medical history is unremarkableSeverity = Mild to Mod (pain 5/10 at worst, Mild interference with ADLs/work tasks)
Irritability = Mild (Able to reproduce symptom with 1 bout L cervical rotation, however, eases quickly after returning to resting position )
Nature: R C4/5 facet
Stage: Chronic
Stability: SQObjective:
Cervical AROM: flexion: 60 deg, extension 30 deg , Sidebend right 45deg, sidebend left 35 deg, rotation right 80 deg, rotation left 55 deg R sided neck pain
(+) L cervical extension quadrant with pain on the R
Cervical endurance test: chin tuck x 5 seconds with PBU at 22 mmHg
(-) Sharps Purser , (-) Transverse ligament test
(-) Modified Deklyns Test for VBI
Accessory mobility: hypomobile C2/3 on the R and C4/5 on the R, as well as hypomobile C7/T1, upper and mid thoracic spine
Neck Disability Index = 30%
Impact Event Scale = 22Asterisks:
L cervical rotation = 4/10 p! R sided neck pain
PA/side glide to C4/5 on R = 4/5 P! R sided neck pain
Limited L cervical extension quadrant = 5/10 p! R sided neck painTreatment:
Day 1:
Grade III/IV PAS to C2/3 and C4/5 on the R –>; L cervical rotation 60 deg 2/10 p! ; PA C4/5 = 3/10 p! improved mobility
Grade V supine AP to upper and mid thoracic spine & Grade V seated CT junction distraction –> L rotation = 2/10 p! 70 deg , side glide to C4/5 = 3/10 SQHEP:
Supine chin tuck
Self mobilization in cervical L rotation with pillow case
Self thoracic extension mobilization with towel roll in chairPICO:
Is the addition of thoracic manipulation with Deep Neck Flexor training (DNF) better at improving pain, ROM, and disability compared to DNF training alone in a 53 y.o male with chronic neck pain?Discussion Questions:
– What other screening tools, objective measures would you utilize with this type of patient? Other treatment strategies to implement?
– Based on the patient’s SINSS was the vigor of the examination appropriate?
– Are you utilizing some objective asterisks/comparable sign with your patients? – If so, how have you found this beneficial?
– Do you utilize DNF training and thoracic mobilizations/manipulations in all your patients with neck pain? Why or why not?
– What decision making do you use in deciding to utilize thoracic manipulation vs mobilizations?
– What techniques are you typically utilizing in the thoracic spine?
– What is your typical progression of DNF training? -
Brett – Thanks for posting this interesting case. Just to clarify, you had findings of:
hypomobile PAIVMS C2/3, C4,5 on the left,
asterisks PA/Sideglide to C4/5 = 4/5 pain on the right. This was with P/A left? Sideglide left?
What were your findings with PAIVMs to C2/3 and C4/5 on the right?
Thanks!
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Brett, thanks for posting this case, as I am sure this mirrors a lot of the patients we see post-MVA.
About the objective details of the case, did palpation of the anterior and posterior neck muscles recreate any of his pain? What was the tissue quality like? Was resisted cervical motion more or less painful than AROM? One screen that I saw recently to consider more of a muscular component of hypomobility and pain in the neck was unweighting both arms and rechecking SB and rotation AROM to see how much the motion might improve. You also said this patient is hypomobile throughout his upper and mid T spine, but what is his upper and mid back muscular strength like and what are his biggest deficits for thoracic AROM with overpressure?
To answer some of your discussion questions:
I think for nearly every neck pain patient I have I prescribe some level of DNF training. The first reason for this is that every patient demonstrates decreased endurance in these muscles whether it be due to pain, atrophy, fatty infiltrate/histological changes, or postural/habitual. And similar to performing painfree mid AROM in the cervical spine, I’ve found that just finding a neck movement exercise that is not pain provoking and creating some movement overall can be a big first step for the chronic neck pain patient. As for progression, I typically start patients in sitting versus supine as I’ve found that even patients with moderate pain and irritability tend to not tolerate performing the traditional 10 second 10 rep cycle in supine. I then progress to performing upper and mid back exercises while also performing a chin tuck in standing. For thoracic manual therapy in the past I’ve primarily used mobilization of the T spine as a way to decrease pain in the severely irritable neck and manipulation of the T spine in the few patients I have seen with cervical radiculopathy. I think I’d like to start using T spine manipulations in the way you have done here and we talked about during the first course weekend as a quick primer for other treatments.As for the article, a couple things stand out. They spent 10 minutes on thoracic manipulation in group A, which certainly could have been spent performing lower grade mobilizations instead of HVLATs. I would love to see a comparison of the two if you spent the same time on each, as one of the biggest draws for me when performing a manipulation is how quick the treatment is. I was also surprised at how large of an improvement these chronic neck pain patients demonstrated, although part of this might be attributed to receiving 30 sessions of PT over the course of the trial.
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August one of the progressions that I find helps patients when progressing DNF training to standing with UE challenge is with use of a laser. I have them go into a chin tuck position and I place a sticky note on the wall, I next have them perform UE challenges (shoulder ext,scapular retraction, bilateral rows) while maintaining the laser on the point. I find the visual que really helps some patients maintain the position.
I agree with your thoughts on seeing the comparison of using the 10 minutes on low grade mobilizations instead of a thrust technique. I tend to spend more time doing low grade mobilization and soft tissue work, along with ROM exercises vs a thrust technique. I think this is partly due to my lack of experience and confidence performing a comfortable thrust techniques for the patient.
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Thanks for the case Brett.
In regards to the discussion questions you posed:
I think I may have screen the patient’s shoulders. Just as we often find relevant hip asymmetries with LBP patients, I feel we can find relevant shoulder asymmetries when treating cervical pain. I also may have screened his upper quarter neurodynamic mobility, just to assess the involvement of his neural/dural tissue.I have found utilizing objective asterisks to be very useful for both myself and the patient. Initially I was using 5-6 asterisks I would check every visit but I have learned it is better to pick 2-3 that I want to check each visit. This helps me monitor progress and also helps the patient note improvement in their condition, which is potentially more beneficial.
I try to utilize DNF training and thoracic mobility intervetions with almost all cervical patients. As for choosing between t-spine manipulation vs mobilizations, I typically choose manipulation if there are no contraindications to the intervention and I can based on the patient’s body size. The literature shows t-spine manip to be slightly more beneficial that t-spine mobilization, so if possible, I choose manipulation.
As August mentioned his progression, mine is similar. Once they understand the chin tuck and nod and can maintain form, I progress to performing periscapular strengthening exercises while maintaining the chin tucked position (such as a low row to improve lower trap activation and additionally to promote thoracic extension). I have also used a mini theraball against a wall with the patient standing at a 45 degree angle and perform a nod against the ball (theoretically getting a greater unilateral contraction of the DNF).
I would like to know how other progress DNF activation exercises as well. I think I could improve on my progression.
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Thanks for posting this case.
As August already pointed out I think adding a step to your screen and unweighting the UEs to see if motion changes is helpful, especially with a patient s/p MVA as some level of muscle guarding/stiffness may be present. I think the Patient’s SINSS warranted the approach you took. Had his irritability been higher I may have decreased the amount of manual intervention performed. I think it is challenging when you have a patient with moderate-severe irritability and you want to include multiple manual techniques. Sticking to one or two techniques that will maximally benefit the patient and have minimal chance of flaring patient’s symptoms up is more important with those patients so that the provider-patient trust is not affected.
I think use of asterisk signs is very beneficial for both the PT and the patient. It is a way to assess if you (the provider) are treating what you are attempting to treat and it can create patient but-in immediately if you bring the patients attention to a change made within one or two visits. I like having at least one asterisk sign that is purely objective and not related to pain, which I find hard with some patients, especially one like this where his severity and irritability are lower. I have typically seen with these patients they are able to go through most screening and objective tools with little to no limitation and only have their symptoms in extreme positions or with endurance tasks making it harder to test-retest quickly and effectively.
I use DNF with most patients with neck and thoracic pain, however I do not always use thoracic intervention with patients with neck pain. My decision making for use of thoracic mob/manip intervention includes assessment of the patient’s thoracic mobility actively and with PAs in supine. I feel much more specific with mobilizations so I will target a specific segment and motion if I feel I can make a change in the patient’s mobility this way. I will use manipulation if the patient seems grossly hypomobile or if I am not making the change I would like with mobilization. I feel most comfortable with the supine/hooklying thoracic spine manipulation and I will modify it with a bridge for the upper thoracic spine. I utilize the prone manipulations similarly to when I am mobilizing. I feel more specific when utilizing the prone technique, but not as effective. I have much more experience with the supine technique.
I progress my DNF training similarly to August as well. Usually I start in supine and progress to seated and then to standing. Sometime this depends on where the patient’s functional limitation is (sitting v. standing). I have also found it to be beneficial for some patient to add a step from supine to against a wall so that they have gravity against them, but also have a surface for feedback similar to when they were supine. Once getting in a functional position I then add in challenges with the UEs.
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In terms of other screening tools and objective measures, as Austin mentioned, I would be interested to see if palpation of the anterior and posterior musculature reproduced any symptoms. Additionally, if there would be any change in active cervical rotation when slackening the upper trapezius. Based on the patient’s symptoms, the vigor of the exam seemed appropriate. If I am going to try to provoke all of a patient’s symptoms, it is important to me that they have only mild to moderate irritability or I have determined a position of relief, which can be difficult at times. I notice that I tend to build a greater therapeutic relationship with patients when they see that I can reproduce and alleviate their symptoms. I also agree that using asterisks/comparable signs to be very beneficial for me as well as the patient. As Erik mentioned, I like to try to have at least one asterisk that is not pain dependent. I have noticed that having 2-3 comparable signs is a good number as when you are comparing from one visit to the next, the patient’s irritability/symptoms have hopefully reduced and something that once reproduced symptoms may no longer be positive the next visit.
I have used some form of DNF training with all patients with neck pain, and tend to progress in a similar fashion to how everyone has described. In addition to adding DNF with upper extremity strengthening, I have had patients perform functional tasks as well. In terms of thoracic mobilization, I will utilize it with most neck pain patients, however it may not be in their initial evaluation or even first treatment. I mostly utilize a thoracic PA mobilization, as at this point in my career I am more comfortable with mobilizing versus manipulation. I hope to progress towards using more manipulative techniques as I become more comfortable with them.
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I agree that I would have screened out UE involvement even with a subjective report of no shoulder/UE limitations. I most likely would not have performed neurodynamic testing on the initial visit due to the (-) findings in your Csp testing. I am curious as well, about soft tissue involvement due to R sided symptoms w/ L SB and rot but I would be more inclined to consider a facet opening restriction first and assess soft tissue if improvements were not being made.
As far as SINSS model, I think the testing was of appropriate vigor. I think you definitely want to find symptom provocation but in ways that do not skew your further testing. I do have one question for you regarding quadrant testing, do you always include quadrants even after (+) symptom provocation in cardinal planes? I have found that some cervical pts have (+) quadrants due to irritability that might not fit the rest of the clinical presentation and I think that clouds my clinical reasoning process some, how do you tease out the things that don’t fit without just ignoring them?
I think having a few comparable signs helps to streamline the follow up visits and somewhat simplifies and aligns tx goals w/ pt outcome goals, which improves pt buy in when they can see clear improvements. Aaron also preaches using therex that complements your tx and I find it makes therex choices and decisions easier when you have comparable signs as guidelines.
In our technology based world constantly staring at screens and often with shoddy posture, I think most pts will benefit from DNF training, and Tsp mobility, especially those w/ symptomatic Csp dysfunctions. As long as there are no contraindications to manips, I try to use those often, if nothing else, just to practice my feel for different spines and different hand placements. I haven’t used Csp manips as much as Tsp, mostly because of my personal comfort level, but also because of the evidence (I can’t remember the article at the moment) showing that Csp manips are relatively similar to mobs in decreasing pain and improving ROM.
As far as my progression is concerned, I try to use isolated DNF training first in sitting/supine/prone depending on pt comfort level and ability to engage the correct positions and then progress to scapulothoracic stability while maintaining proper DNF activation. It has been very interesting to get other perspectives on this, especially with the use of lasers. I have not been exposed to that in my prior clinical rotations but I can think of a handful of current pts that may benefit from using it.
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Similar to other posts…
I agree I would have liked to look at muscular source of pain via unweighting of shoulder girdle or resisted cervical motions, as well as neurodynamic testing. I believe the patient’s min irritability would allow testing of these structures without too much provocation.
Other tools I might consider with this patient (depending on presentation) might be an FABQ. I did an in-service on a CPR from Ritchie et al in PAIN in 2013 that showed if they are over 40 years old AND score highly on the Post Traumatic Diagnostic Scale – hyperarousal subscale (PDS – http://www.ptsd.va.gov/professional/assessment/adult-sr/pds.asp ), then they are more likely to have chronic symptoms/not recover fully. I’m not advocating for CPR’s here, it just an interesting study to look at, and I have attached it. The PDS is not free, sadly, but maybe we could substitute the FABQ or a similar scale and repeat the study?
I am trying hard to incorporate a 2-3 quick subjective asterisks AND 2-3 quick objective asterisks to start each session, but I am far from consistent in doing this and need to improve.
Since the first VOMPTI weekend I have been using thoracic manips on every patient where they do not have contra-indications in order to practice my skills. I will use mobilizations on those who are not appropriate for manips. Would love to see a study in the C-spine similar to what we see in the L-spine i.e. manip and then see if changes in muscle activation in longus coli post (has this study been done?)
Techniques I have been practicing – seated CT junction manip, supine pistol/grenade manip, prone CT junction manip, prone rotatory manip
My progression of DNF training is similar to others, but once they can tolerate some seated activities w/ arm movements, I will progress to prone with head off edge of bed and have them do a few holds for endurance. I think this challenges the DNF while also working on posterior neck muscle endurance.
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