Today's Question Comes from Dr. John Feil, DPT who is having trouble with a cervical patient that a neurosurgeon wants to operate on.
The pt is a 47 yo female who states she has had pain in neck for the past year and a half. Her complaints have worsened in the past 2 mos and now include B UE radicular symptoms. Pt had a MRI a year and a half ago that showed multiple cervical herniations and recently had a follow up MRI 1 month ago showing progressing degen of the C3-6 discs and now cord compression from those discs. The pt works as a PT aide in an outpatient facility 7-3 and does part time house cleaning.
She went to see a neurosurgeon 2 month ago when she started having difficulty holding objects w/ left hand and intense pain down R UE. I have been working on increasing thoracic mobilty, PNF to scapula since she has limited post depression, some deep cervical flexor strengthening, and postural re-education. I also have been employing some neurodynamic techniques for ulnar and radial nn. She feels better after Tx but gets stiff again next day. I have also tried light tissue work to the subcranial region, traction with a towel, METs to improve cervical rotation, and cervical retraction for HEP.
My question is can manual therapy have a positive outcome? The neurosurgeon showed me on the MRI some cord compression by herniated disc from C3-7, showing minimal CSF on the films. He states nothing can help her and she needs surgery. She does not have any LE or ambulatory difficulty. I know surgery is only thing that will change things internally but my thoughts were if we can help her adapt to what she has maybe she diminish her symptoms. Pain is one thing, but decreased motor function is something I am a little worried about. I would love to get your opinion on a case such as this.
Here are my thoughts John.
Can manual therapy/pt interaction have a positive outcome? Absolutely, our training allows us to have very detailed physical examinations that take the patient's entire presentation into the picture, not just what their spine looks like when they lie in a tube. Unless someone has red flags or severe myelopathy, that is unchanging with mechanical or positional means, I do not worry about what their scans say. We can do a much better job functionally evaluating a patient when we are not biased by what their crappy MRI looks like. Research has proven time and again the severity of a person's complaints does always equal the severity of their scans.
Here are some suggestions for the patient
- are you pushing her to end range cervical retraction and is she moving to end range herself with self generated overpressure on her maxilla
- this often makes the difference in HEP, and she should absolutely be performing it ALL DAY
- if she gets improvement upon leaving, but it does not last between visits, you may need to up the frequency of her HEP, especially if she is only performing retractions a few times/day like most patients
- is she using a lumbar roll?
- is it EVERYWHERE she sits? Or just in the car or at work - not good enough if she is getting transient improvement
- what is her sleeping position?
- for HA, she may try prolonged cervical retraction over a pillow, 2-3 minutes to see if her complaints centralize
- Have you treated the lateral upper arm and anterior/posterior radial bony contours of the right radius with functional release or IASTM? Check and recheck radial neurodynamics after doing so
- You mentioned by email that Mulligan MWM helps her right lateral epicondylagia complaints, show her how to do this hourly and test/re-test with neurodynamics
- if cervical retraction with OP helps, but not completely, try cervical retraction with extension, make sure she gets to end range extension and follow the MDT rules, it's ok if it hurts, as long as it either improves or does not remain worse upon finishing the movements
- have you checked 1st rib?
- to improve her cord neurodynamics, try sliders with subcranial shear distraction - when you shear or perform your towel traction, have her anterior tilt, perform reps of this and progress to shear distraction or towel traction with posterior tilt for tensioners
I cannot stress her posture/HEP enough, especially if she gets relief that does not last. You have not tried everything until you 100% stress HEP as an all day/hourly event. "Only if you want to get better." Is one of my sayings. None of this is guaranteed of course, but if she is still working as an aide and cleaning houses. I would hold off on a surgery with poor to fair outcomes compared to our conservative treatment. Keep us updated and good luck!