(Previously Derangements 1, 2 and 7)
Introduction
This category encompasses a large proportion of all derangements. Patients report pain centrally or bilaterally in the neck, or across both shoulders, or across both scapulae, or some combination of symmetrical symptoms. Occasionally patients may also report aching bilaterally into both arms. This group comprises those formerly classified as Derangements 1 and 2, and 7. This is a non-specific somatic disorder. Most derangements in this group respond to the extension principle, and a few respond to the flexion principle. Sections in this chapter are as follows:
extension principle
history and examination
• management gUidelines
review
• deformity of kyphosis (previously Derangement 2)
flexion principle (previously Derangement 7)
• history and examination
• management guidelines
• review.
Extension principle History and examination
A table of clues as to the need for the extension principle is included in the previous chapter. Patients may present in the acute or chronic stage with constant or intermittent symptoms. Most commonly patients have central or symmetrical symptoms around the lower cervical spine. Sometimes these can radiate to the shoulders or scapulae. Symptoms may worsen or be initiated by flexed activities, such as prolonged sitting at a computer, driving or reading. Patients frequently report symptoms improve or ease when on the move and walking about, when the neck tends to be more extended.
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CHAPTER EIGHTEEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYSitting posture is often poor, with reduced lumbar lordosis causing a protruded head posture with concomitant lower cervical Oexion. Correcting the posture may centralise or decrease symptoms or sometimes increase them. There is loss of extension, and in more severe cases flexion and lateral movements may be reduced. If lateral movements are affected, there is equal loss to the right and left.
The response to repeated movements will be characteristic. Repeated protrusion or flexion and sustained slumped sitting cause symptoms to increase or spread out from the spine. This response is linked to the number of repetitions or the length of sustaining the Oexed posture, and so may not always be immediately apparent. Indeed, in the more acute patient, prolonged exploration of flexion movements should be avoided.
In contrast there will be a positive response to retraction and/or extension, with a decrease or centralisation of symptoms and an increase in range of movement. Often this response may become apparent during several repetitions of the test movements on day one. This response, though, might not be instant, but emerge over several days of repeated movements and posture correction. Often in such cases the beneficial response to the extension principle is confirmed at review twenty-four to forty-eight hours later, when a clear improvement in symptomatic and/or mechanical presentation is noted. Much can be achieved using patient-generated forces in the first few days, and in this way the patient can realise and experience the extent to which self-manage ment can improve their problem. Therefore it is generally undesirable to use clinician-generated forces during the first session.
Most patients in this category respond in the loaded position and are able to do the exercises in sitting or standing. This has the advantage of being easy to apply during everyday activities. A minority of patients, with more severe or acute presentations, may need, at least initially, to be treated in an unloaded position. Because this is much less functional, exercising in the sitting position should be started as soon as the response is favourable.
Management guidelines Procedures to be used:
MANAGEMENT OF DERANGEMENT - CENTRAL AND SYMMETRICAL SYMPTOMS
• retraction with patient overpressure - may be needed to regain retraction prior to extension (Procedure la)
• retraction and extension - usually essential (Procedure 2) • posture correction - essential for reduction and maintenance of
reduction (Procedure 3). Regularity:
• ten to fifteen repetitions every two to three hours. Expected response:
• centralisation, abolition or decrease of symptoms possible increase of pain centrally initially
• increase in all ranges of movement that are restricted.
Maintenance of reduction:
• regular performance of retraction/extension exercises to maintain symptomatic and mechanical improvements
posture correction when sitting • if symptoms recur when lying:
trial of cervical roll
trial reduction of pillows
• maintenance of retraction when rising from lying.
• see Chapter 17, section on Maintenance of reduction, for more detail.
Force alternatives
If the patient is unable to regain retraction or extension in the loaded position, the same movements are attempted unloaded. This require ment is unusual, but may occur in severe or acute derangements or if the patient is apprehensive about performing the exercises in sitting.
retraction in supine (Procedure 1)
retraction and extension in supine (Procedure 2) retraction and extension in prone (Procedure 2).
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CHAPTEP- EIGHTEEN THE CEP-VICAL & THOAACIC SPINE: MECHANICAL DIAGNOSIS & THEAAPY Force progressionsForce progressions are used only if improvements plateau or [ail to occur. Before undertaking progressions, the patient's exercise technique and postural correction should be checked. Progressions should never be instigated if the patient is able to decrease or abolish symptoms, but these return due to failure to maintain reduction of the derangement. Progressions may also be used to confirm an initial diagnosis if there is some uncertainty; in other words, the procedures are used as part of the assessment process.
only use one new procedure per session
• wait twenty-four hours before initiating further progressions • repeat force progressions a maximum of two sessions if no definite
improvement occurs
• the patient must continue with home exercise programme,
otherwise any benefit from the force progressions will be lost between treatment sessions
• force progressions are stopped once the patient is able to self manage
• retraction with clinician overpressure (Procedure 1 b) - some times this is reqUired to enable the patient to regain enough retraction to perform extension adequately
• retraction and extension with rotation and clinician traction supine (Procedure 2b)
• retraction mobilisation (Procedure Ie). Review
When the patient returns for review they will be improved, worsened or unchanged. Ensure that the status reported by the patient is their true state. Patients may report their symptoms to be worse when widespread pain has centralised to the middle of the spine; they may report themselves to be unchanged when in fact pain that was constant has become intermittent. Some patients, keen to please and to get better, report an improvement that is difficult to confirm. See Chapter 12 for details of how to analyse clinical presentations and Chapter 13 for the structure of a review process.
Patient is better
If there is improvement in the symptomatic and/or mechanical response at review, management strategy should not be changed.
MANAGEMENT OF DERANGEMENT - CENTRAL AND SYMMETRJCAL SYMPTOMS
It is unnecessary to supplement present procedures with any other techniques or interventions if the patient is getting better. Management continues in the same way unless there is a change in status. Once symptoms are minimal, the frequency of exercising may be reduced if this seems appropriate, and the patient should be told also about performing the exercises at the first signs of recurrence. Main tenance of reduction through the use of posture correction should be reinforced, and the slouch-overcorrect procedure could be introduced to allow the patient to appreciate the different sitting positions. Patient is worse
There are certain instances that the patient may interpret as being 'worse', which we would not consider as such. When centralisation occurs there can be an accompanying and temporary increase in central pain. When patients with long-standing derangements and an associated obstruction to extension commence the necessary extension principle, procedures there can sometimes be an initial short-lasting increase in symptoms. The patient may be performing the procedures incorrectly or may have misinterpreted instructions and be doing different exercises. New pains may have appeared as a consequence of performing the exercises, which has made the patient reluctant to continue. Do their symptoms improve with the exercises, but get worse later because of insufficient attention to posture7 Did they initially get better with the instructions, but then worsened because they increased their activity level too soon? All these instances should not be considered a worsening scenario.
If really worse, pain is usually more widespread. It should be ensured that the patient definitely has symmetrical symptoms. If a condition is truly worsening, the patient should be advised to stop the exercises - patients sometimes improve with this step. If unequivocally worse, their response to flexion principle should be explored. If there is still a worsening response to all procedures, non-mechanical conditions should be considered.
Patient is unchanging
First it should be ensured that the patient is performing the right exercises correctly and with enough regularity, and that they are complying with postural instructions. If this is not the case, further instruction and discussion are necessary to ensure that the patient understands the procedures and their own role in managing the problem. It is best to see the patient daily until certainty of management is established
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CHAPTEft EIGHTEEN THE CmVICAL & THOftACIC SPINE: MECHANICAL DIAGNOSIS & THEftAPy and the patient is confident about their management strategy. If the patient cannot be reviewed regularly, this can create problems. In such cases attempts to review by telephone are desirable.If they have been following the treatment principle correctly, but still no improvement has occurred, then force progressions should be implemented. These are done in the following order, with subsequent force progressions applied only if there is failure to improve. If at any point improvement does occur, further progression is unnecessary. Whatever progression is used, the patient must continue to perform the appropriate exercises at home with suitable regularity. Following a force progression, the effects of this procedure should be evaluated at the next review. Force progressions can be repeated on up to two occasions before they should be abandoned if no change ensues. Do not instigate clinician techniques unless it is clear that improvement cannot be achieved by any other means.
• wait twenty-four hours before initiating further progressions
• repeat force progressions a maximum of two sessions if no definite
improvement occurs
• the patient must continue with home exercise programme, otherwise any benefit from the force progressions will be lost between treatment sessions
• force progressions are stopped once the patient is able to self manage
• retraction with clinician overpressure (Procedure Ib)
• retraction and extension with rotation and clinician traction
supine (Procedure 2b)
• retraction mobilisation (Procedure Ic).
Deformity of kyphosis (previously Derangement 2) This is a rare and acute presentation in which patients usually have central or symmetrical pain. Extension is obstructed and the patient's head is fixed in protrusion and flexion. Symptoms may radiate bilaterally into their arms. Any attempt to extend the neck gives rise to severe twinges of pain, and the patient avoids such movements by maintaining a flexed posture.
MANAGEMENT OF DERANGEMENT - CENTRAL AND SYMMETRICAL SYMPTOMS
It is impossible to carry out a normal physical examination in such a patient as all movements will be extremely limited and repeated move ments are too difficult to perform. However, the obvious deformity and inability of this patient to move normally allows easy recognition. If the patient developed the deformity as a result of some trauma, such as a fall or motor vehicle accident, no clinician-generated forces should be used and imaging studies should be undertaken to ensure no serious spinal damage has occurred.
Response to attempts to reduce these derangements is variable and often limited. Sometimes, in the presence of a 'soft' deformity, patient generated forces are successful in beginning the process of reduction. In the presence of a 'hard' deformity, sometimes clinician-generated forces are necessary to start this process. Often recovery is protracted even when patients do respond, taking several weeks to fully regain extension. Unfortunately some make only minimal improvements.
Because of the nature of the derangement and the difficulty of per forming any movements in a loaded position, treatment is always done unloaded.
Procedures to be used:
the patient should be laid down with head resting on pillows and/or raised treatment table end so that the flexion deformity is accommodated
• retraction in supine in kyphotiC deformity
• depending on symptom response, the treatment table end is
lowered/pillows removed slowly and gradually, thus letting the head drop back into neutral and then extension
• retraction/extension in supine or prone (Procedure 2)
if the patient starts to respond they should continue with retraction/ extension supine or prone at home (Procedure 2)
extension with traction and rotation in supine may help to regain extension and might be used from day two for several sessions
as soon as possible the patient supplements unloaded exercises with retraction and then retraction/extension in sitting.
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CHAPTER EIGHTEEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYFlexion principle (previously Derangement 7)
History and examination
There may be certain clues found during the history-taking and physical examination that suggest the flexion principle should be used, which are listed in the previous chapter. The patient might report that they have anterior as well as posterior neck pain and that they have pain or problems with swallowing. Such derangements can result from road traffic accidents. On examination there will be marked loss of flexion, but full-range pain-free extension. This presentation is relatively rare.
Management guidelines
Management is conducted entirely in the sagittal plane using flexion forces.
Procedures to be used:
• flexion - essential (Procedure 6)
flexion with patient overpressure - essential (Procedure 6a). Regularity:
ten to fifteen repetitions every two to three hours. Expected response:
• centralisation, abolition or decrease of symptoms
• possible increase of pain centrally initially • increase in flexion range.
Review
When the patient returns for review they will be improved, worsened or unchanged. Ensure that the status reported by the patient is their true state. See Chapter 12 for details of how to analyse clini�al pre sentations and Chapter 1 3 for the structure of a review process.
Patient is better
If the patient reports an improvement in symptoms - centralised, abolished or decreased in intensity of frequency - this should be con firmed by a mechanical change; that is, an increase in flexion range. It is unnecessary to supplement present procedures with any other techniques or interventions if the patient is getting better. Management continues in the same way unless there is a change in status.
MANAGEMENT OF DERANGEMEN T - CENTRAL AND SYMMETRJCAL SYMPTOMS
Patient is worse
If really worse, pain is usually more widespread. It should be ensured that the patient definitely has symmetrical symptoms. If a condition is truly worsening, the patient should be advised to stop the exercises - patients sometimes improve with this step. If unequivocally worse, their further response to extension principle should be explored. If there is still a worsening response to all procedures, non-mechanical conditions should be considered.
Patient is unchanging
First it should be ensured that the patient is performing the right exercises correctly and with enough regularity. If this is not the case, further instrucLion and discussion are necessary to ensure that the patient understands the procedures and their own role in managing the problem. It is best to see the patient daily until certainty of management is established and the patient is confident about their management strategy If the patient cannot be reviewed regularly, this can create problems. In such cases, attempts to review by telephone are desirable.
If they have been follOwing the treatment principle correctly, but still no improvement has occurred, then a force progression should be implemented. Do not instigate clinician techniques unless it is clear that improvement cannot be achieved by any other means. Use of cliniCian-generated forces in this derangement is rare.
• the patient must continue with home exercise programme,
otherwise any benefit from the force progressions will be lost between treatment sessions
• force progressions are stopped once the patient is able to self
manage
flexion with clinician overpressure (Procedure 6b) flexion mobilisation (Procedure 6c).
Conclusions
This chapter has described management of patients with central or symmetrical neck pain from a derangement. All such patients require only sagittal plane forces, most need retraction and extension exercises, and most can perform these in sitting. In a very small proportion, symptoms are accompanied by a deformity of kyphOSiS; extension forces are also required, but must be performed unloaded. Some
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CHAPTER EIGHTEEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYpatients with central or symmetrical symptoms require flexion forces. Features from the assessment, the management gUidelines and the review procedures are also detailed in this chapter.