Follow up: Case Study: Cervical pain post concussion

Follow up to Case study: cervical pain post concussion

I treated patient on 11/13 two days after the initial evaluation. Patient reported that her neck pain and movement was a lot better and working on HEP throughout day including at school. She continues to have no headaches or dizziness. Her major complaint now is with sidebending and lack of activity. She really wants to be ready for indoor soccer season which starts in a couple weeks.

Re-check of measurements:

  • Bilateral Rotation and sagittal AROM of cervical remains full and only a 1/10 pain (in upper traps)
  • Her cervical retractions look great and can repeat without incident
  • Thoracic rotation actively is good
  • Upper trap spasms continue but subjective report of much improvement and no more medial scapular border pain
  • Sidebending is limited to about 50% of max (she has a long slender neck and should get a lot of motion in this directions) and has moderate pain

Treatment

  • C-T distraction again
  • IASTM to upper traps and cervical paraspinals
  • Weight bearing cervical retraction with sidebending
    • Reported a lot of pain and was apprehensive to continuing
  • Non-weight bearing cervical retraction with sidebending
    • Tolerated much better and performed until able to get what looks like full PROM
  • Revisited the weight bearing cervical retraction with sidebending
    • Able to tolerate now and improves her motion and pain but still not full AROM that she had passively and pain is still present.
  • Supine mobilizations of cervical segments (right to left and left to right)
    • Moved into more closing with reps
    • Rechecked AROM sidebending and now improved and only mild pain to perform
  • Attempted Upper rib manipulation to left side to reduce upper trap spams but unable to get a good lock and no cavitation. Did on right side and same result
  • Bike, bird dogs, mid/low trap (T/Ys), planks and squats
    • Performed some mild exertion activities to increase blood flow and to begin exertion training for return to sports.
    • No neck pain and no concussion symptoms throughout this part of the program
  • HEP:
    • Same as previous, added the exertion components listed above, cervical retraction with sidebending and also gave a towel pull (isometric horizontal abduction) with row.
    • The towel pull with row seems to get some scapular retraction without flaring up the upper traps

What could I have done different? What would you have done differently?

Any advice on the sidebending? Any advice on upper trap/cervical spasm reduction?

What would you give next visit?

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.