Case study: Cervical Spondylosis

Case study: Cervical Spondylosis

The following case study gives you an idea of what treatments may be considered for this patient. This is a brief overview. Any CPD or case study for university would require much more depth and must be evidence based and demonstrate clear clinical reasoning. Many examples of these can be found through Pubmed and these should (alongside university guidelines)  be used as your outline for graded work.

Introduction

A 70 year old women presented with a three month history of neck and right shoulder pain. Symptoms were insidious in onset and she reported no pins and needles or paraesthesia on a day to day basis. She described that symptoms are worse when she first wakes up and at the end the day after shes been knitting. She also reported that looking over her shoulder when reversing her car had become particularly difficult. She found that lying down helped ease her symptoms although occasionally this caused pins and needles in her right hand if she had too many pillows. She had visited her GP who had advised NSAID’s as needed and he had also sent her for an X-ray. The X-ray confirmed cervical degeneration of the discs C3-C6 with mild osteophyte formation. He had been advised that physiotherapy was the best management at this stage and referred her on.

Clinical Impression

The findings of the objective assessment fitted with osteoarthritis. A full neural examination showed that reflexes, dermatomes and myotomes all appeared normal. The patient presented with poor posture and had an increased kyphosis and forward head posture. There was tenderness in the upper trapezuis muscle bilaterally and cervical paraspinals.There was tenderness on palpation on C2-7 PAVIM’s and adjacent facets. Cervical ROM was reduced (extension 70%,  flexion 80%, left rotation 50%, right rotation 50%, bilateral sideflexion: 50%) which fits with a cervical capsular pattern.

Treatment goals

  • Treatment goals were discussed and formulated with the patient.
  • Reduction of cervical spine and right shoulder pain.
  • Restore active ROM of the cervical spine.
  • Complete 30 minutes of knitting before onset of pain.

Treatment Plan (“Tool box”)

  • Contraindications considered (ie oseteophytes therefore nil Gv manipulation. Age: consider osteoporosis)
  • Explanation of degenerative nature of pathology and therefore self management strategies.
  • Posture re-education: Use of side profile photographs to educate the patient about retraction and optimal posture (to offload soft tissues and facet joints).
  • Joint mobilisations (Grade I and II for pain and Grade III and IV)
  • Stretches
  • Tens
  • Ultrasound
  • Cyrotherapy
  • Heat
  • Traction
  • Acupuncture

Treatment 1

  1. Patient was educated on posture and pictures were taken with permission from a side profile. Explanation on forward head posture and its effects on the facet joints and discs were discussed. Patient was unable to achieve an optimal position. The patient was asked to stand with back against a wall and a book held behind the head. A retraction was achieved with this distance and the patient described a ‘nice stretch’ at the back of the neck. Patient was advised caution with this exercise and to discontinue if produces pins and needles, numbness or dizziness.
  2. Hi- TENs ( no contraindications) applied for 10 mins to C5 nerve roots.
  3. Home exercises program(HEP) : Cervical retractions x 5 6-7 x daily , Gentle rotation with over pressure x 3 with 30 sec hold x2-3 daily, tall posture with 5 sec hold x 5 x 2-3 daily.
  4. Advised heat and ice techniques at home.

P/ Review 1/52

Treatment 2

  1. Reviewed HEP. Photos of side profile retaken with permission. Improve posture.
  2. SIN factor was low therefore joint mobilisations were performed in prone however a forward seated head support may be beneficial if the patient found transfers aggravating. Grade II AP/PA PAVIM were performed at C3-6.
  3. Ultrasound to C5 and C6 and right facets (based on subjective findings) 3mhz, 1:2, 0.3w/cm2, 5mins.
  4. Traction x 30 sec x 3.

P/ Review 1/52

Treatment 3

  1. Gentle Snags with left rotation C 2-7 x 3.
  2. Ultrasound to C5 and C6 and right facets (based on subjective findings) 3mhz, 1:2, 0.3w/cm2, 5mins.
  3. Deep neck flexor strengthening in supine – tolerated well (added to HEP).
  4. Auricular acupuncture

P/ Review 2/52

Treatment 4

  • Stressed importance of continuing HEP as part of a long term management strategy.
  • Details of how to purchase a TENs machine if necessary.
  • Gentle Snags with left rotation C 2-7 x 3.

P/ Advised to contact GP for re-referral if re-exacerbation of symptoms.

Conclusions

With ever growing stresses on the NHS there is increasing pressure to treat with a hands off approach and treat self management strategies. Education on the principles of treatment and aims help patients to understand and manage pain independently where possible.  This patient received four treatments through a private provider of physiotherapy through NHS contracts. Treatment was considered effective because all goals were met.

Anatomy

Case Studies

Cervical Spondylosis

Treatments

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