Case Study: cervical pain post concussion

Case Study: cervical pain post concussion

Meant to post this earlier in the week once I saw the patient then update it after seeing her for a second time. Here is the original evaluation then the follow up is at the end of the post.

On 11/11 I had an eval for cervical pain post concussion/whiplash. Prior to seeing the patient I talked to our vestibular therapist to give me an update on her. She was highly symptomatic (headaches/dizziness) last week but today she was doing well with no complaints of headaches or dizziness. The most glaring issue was that she was unable to test any head thrust and VOR measures due to the lack of cervical rotation due to pain.

Subject:

  • High school female soccer (outdoor and indoor) and track athlete.

Past medical history:

  • No prior concussions or neck injuries. Did have bilateral hip pain last year during soccer season but did not have any pain this season.

Incident:

  • Was elbowed in head during a soccer game in the middle of October. Initial symptoms consisted of headaches, dizziness, concentration difficulties and fogginess.

Subjective history of current events:

  • Started having neck pain a couple days after concussion and was in vestibular two weeks after the incident. After first visit vestibular therapist referred her to ortho to address neck pain and to get full AROM so that they could progress on with therapy. She missed the first eval and wasn’t able to get in to see me until 11/11.
  • The pain is constant and gets worse as the day goes on. Hasn’t been involved in any sporting activities or working out due to the concussion. No headaches now so unrelated to neck pain currently though she did report that the neck pain would go up and give her headaches previous to this week.

The initial evaluation:

  • Pain
    • Pain is moderate at rest and severe with cervical AROM
    • Pain centralized to bilateral upper traps and down middle of cervical spine radiating out to the medial bilateral scapular regions
  • Cervical AROM
    • Right/left rotation = 32 degrees with increased pain (severe) on both sides of neck and upper traps
    • Sagittal = 60 degrees with increased pain in both directions (same areas/intensity)
    • Sidebending is restricted to left= 24 and right = 20 with severe pain as well
  • Tenderness (for completeness)
    • Upper traps, sub-occipitals, cervical paraspinals, medial scapular soft tissue and in the thoracic/cervical with P-A over the spinous processes.
  • Strength:
    • Normal shoulder strength and no myotomal weakness
    • Mid/low traps= 3/5, rhomboids= 4+/5
  • PROM
    • Full flexion/extension in supine.
    • Left/right rotations limited due to severe pain but able to get about 75 degrees
    • Sidebending to 45 degrees with severe pain limiting motions
  • The AROM restrictions of O-A, mid cervical vs lower cervical are limited due to the pain
  • Spasms and blocks movement with attempts at any sideglides to cervical region

Treatment

  • PT assisted Non-weight bearing (supine) Mackenzie exercises for extension
    • This includes:
      • Traction with retraction (5 reps) then moved straight into traction- retraction- extension followed by nodding maneuver at end range extension
    • Response:
      • Increased pain with first rep but no red lights -> finished 10 reps
    • I performed to gain extension which often times helps all motions as well. Probably more of a neurological feedback than actually placing anything into proper alignment (helps to decrease apprehension of tissues blocking movement?)
    • Once sitting I re-check motions and had improved flexion/extension greatest but pain at end ranges still. Mild improvements in rotation and pain.
  • Performed C-T distraction and audible cavitation (patient was not impressed! Haha)
    • Improved flexion to near end range with decreases in pain with both flex/ext
  • Weight bearing Mackenzie exercises for extension
    • 10 reps of cervical retraction
    • 10 reps of overpressure
    • 10 reps of retraction- overpressure- extension with nod
    • Full extension now with only mild pain and less upper trap spasms/scapular pain
  • Instrument assisted Soft tissue to upper traps and cervical paraspinals bilateral
    • About 75 degrees of rotation, sidebending is improved but still an issue with pain
    • Reduced spasms quite a bit through cervical region/upper traps
    • I choose to use IASTM vs trigger point releases because…
      • What are trigger points?
      • Seen much better results in session and sustained with follow ups
  • Final: Horizontal abduction pull on theraband with cervical AROM in all plans
    • Just 8 reps of rotation to each side, flexion and extension
    • Full rotation bilateral now with only mild pain at the endranges. Extension and flexion is full and only a 1/10 pain.
  •  HEP:
    • Weight bearing Mackenzie extension exercises
    • Horizontal abduction pull with AROM
    • Weight-bearing thoracic rotation exercise with band pull (was restricted and now full thoracic rotation)
    • Bilateral External rotation with retraction and breathing
    • Patient was finally impressed at the end of the session when she could rotate her head for the first time in weeks.
  • Final thoughts:
    • I always like going NWB manual Mackenzie exercises to start. I feel like it helps the patient adjust more by putting it in my hands vs their own. I always try to finish with HEP weight bearing though.
    • Love IASTM to cervical region for reduction of “spasms”. In my experience the carry over for improvements if you follow it up with the band pull with AROM and Mackenzie exercises is very good.
    • In previous post I love the band pull with AROM when there is a clear limitation in AROM vs PROM. Helps to improve a lot of things including thoracic rotations.
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Active Vs Passive ROM (Cervical Spine)

Active VS Passive ROM (Cervical)

This is my first post relating to active vs passive ROM testing and treatments. I want to start in the cervical region.

One thing that I noticed going through school and then as a floater and now as a clinical instructor is how little therapists respect the great knowledge that you can gain by knowing the difference between active and passive ROM. Many, if not all, therapists check active/passive ROM of the shoulder. We mobes/PROM shoulders that have restrictions in both. If just active is limited but passive is full then we work on correcting the deficits in shoulder strength/control. Why don’t we take this into account throughout the rest of the body?

In school and in practice I see many people using the cervical ROM diagram. It allows us to easily list ROM, pain, stretching, radicular symptoms, etc. in one easy to find/use space. It works well and acts as a quick reference for busy times. The problem is: why is there only one of these on most initial evals? There should be one for active AND one for passive ROM. When one of these diagrams looks like the following:

pain diagram

Then we assume (as manual therapists) that there is a closing restriction on the right side. We then put them supine and check each individual segment for mobility and pain. I don’t want this to turn into a discussion of our palpation skills. That can be saved for another time. In short, they are not good. Have you seen a cadaver?

If AROM is limited in all planes or just one plane but passive ROM is full then we really need to start thinking motor control! If AROM and Passive ROM are both restricted then we do need to asses to see where that restriction is coming from. This passive restriction can have many components and that is where we use our heavily developed manual skills to address then retest and check for improvements. Most times, if there is a passive restriction to motion and you clear that up with manual therapy then there is usually a motor control deficit to follow when you re-test the AROM and PROM. Also, don’t just check that first day but rather continue to check the Active vs Passive ROM.

Passive ROM restrictions is a result of something. It doesn’t just happen (like hamstring tightness which is a very long future post). Often times, if you fix that passive restriction they may have full AROM right after as well. This doesn’t mean that there isn’t a motor control issue to address. This change in AROM can be a result of the neurological feedback that you get with manual therapy. It can help reset the system including the active restraints to motion. Re-test the PROM/AROM the next visit to make sure that the PROM remained. If it didn’t then suspect a motor control issue that is preventing motion on continual basis. Follow your manual therapy up with some motor control exercises and see what happens the next visit. If they are consistent with their HEP then there should be those lasting changes.

When I first started thinking of adding more motor control exercises (opposed to the usual row/shoulder/scapular therex) into my treatment plan I was skeptical that it would carry over from one treatment to the next. Once I saw the results I was excited. I always question how we can be better at treating patients and the thought processes behind certain treatments. If PROM is full and AROM of the cervical region is limited then how can I regain full/painless AROM?

I hear a lot of experts talk about the reasons why we aren’t great at treating patients and areas that we need to improve upon. In the SFMA course I took over the summer (the philosophy behind there treatments pretty much changed the way I treat) they had mentioned that diagnosis is the area that we struggle in the most and that we are passible with the interventions. I don’t disagree with that assessment. We struggle with the “real” diagnosis with many patients, that is, in regards to what are focus should be on. But, I also think we really struggle with our treatments. This includes doing too much, not enough, poor progression, targeting the wrong areas, etc.

The big area that we struggle in regards to treatments is wanting to strength train everyone. Motor control is a huge component of a lot of areas and compensations. This is a talk for maybe my next post and many, many posts after that. For now, let’s talk about just improving that cervical AROM. In some ways I don’t even care what is limiting AROM. AROM involves contractile movements as well as non-contractile structures. If PROM is free and clear then what is more of a concern to me is how I can access that motor control system or nervous system.

It isn’t about strengthening the muscles or stretching non-stop to restore motion but rather about the amount of inactivation that is occurring. The motor control system just isn’t working. Overtime, the patient, somehow, developed a poor movement pattern. This poor movement pattern is possibly a result of a poor nervous system activation. It is not strength! You can do all the muscular strengthening and upper trap stretching you want but if you can’t get the system to respond normally then there will not be lasting changes. The body is a system of nerves, nervous system firing and brain mapping that churns out a desired response.

Try going weight bearing first and then if they can’t complete the below exercises go to supine and work on first.

Pull a thera-band apart into shoulder horizontal abduction with both hands and then have the patient actively rotate their head to the left then right. Once finished with that have the patient relax the band back to a relaxed state. Repeat ten times. Then do the same with any other motion that is restricted.

Horizontalabductionpull

You should see an instant improvement in AROM. It will look cleaner, be less painful and the patient should also instantly see/feel the results. I am not saying that it will be pain-free but there should be a noticeable difference in pain levels as well as AROM. If they are still painful then try some sustained overpressure with movement (at some level of the cervical spine from posterior) while they complete the above exercise. This can provide a little neurological feedback to the system and help with the perception of pain.

There is no one definition of motor control or what happens/why we see altered movement patterns when there is pain present. Why/how the nervous system goes about its processes is poorly understood and needs a lot more research focused on this. Hodges and Tucker have a good article on this process in 2011 (see below). A possible mechanism could be through the nervous system. If we can activate a “core” muscular group such as the scapular stabilizers in the upper quarter then maybe this will feedforward. The goal of this exercise is to get the CNS firing first then performing the abnormal movement hoping that it restores the correct timing/coordination of muscles thereby reducing the perception of pain.

Remember this is just one way of improving that active ROM and should be combined with other techniques and ways to reduce the hyperactivity of the nervous systems in through the cervical region. I will only quickly mention the couple other ways that I use as well but save for another post.

Mackenzie extension (clean up PROM/AROM)

Instrument assisted soft tissue massage to the cervical region (neurological feedback not scar tissue!)

Nerve tensioning/slides/glides/release via David Butler

I intend on going through the rest of my cervical treatment interventions to decrease pain and increase ROM as well as increasing function in following posts. I believe that it is very important to know why you perform the interventions as opposed to just assigning interventions because “you have always done it like that”. My interventions and treatment strategies have changed a lot over time and it is because I am trying to constantly look for ways to improve my outcomes and question the norm.

TJ Slowik PT DPT

Hodges, P.W., Tucker (2011). Moving differently in pain: A new theory to explain the adaptation to pain.

Hodges, P.W (2011). Pain and Motor Control: From laboratory to rehabilitation.