Acute C4-C5 disc lesion

[sanagupta]

Hi!
I have patient of 35 yrs with Acute disc lesion(15 days back) at the C4-C5 ,Mild Disc lesion at C3-C4 level.She complaints of Marked weekness of left shoulder flexors and abductors ..Active range merely 45 degrees.I m using Mobilisation at these levels-central and unilateral,it has improved her pain dramatically.I want to know that if electrical stimulation is safe and can help in increasing the range of motion of her shoulder muscles.
Any other suggestions for her quicker recovery

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[bhani]

HI !
I have just read your query and i dont think that electrical stimulation will be a problem to use also you could try hold relax and PNF techniques to help her improve her range .

[kparanipt]

Hi,

Find out the problem, whether it is due to disc lesion or shoulder problems? If it is muscle weakness, i would suggest that PNF techniques of rhythmic stabilization & contract relax method.

good luck.

[sdkashif]

Try the cervical traction and it will help better in relieving the root compression signs and symptoms. Have a look over this link for detail review on cervical traction.

www.thesaundersgroup.com/cervical.pdf

[sanagupta]

Hi!
thanx for all ur valuable suggestins..and as for now..she has improved a lot..with no pain,and full flexion and abduction ranges but the problem is the fatigue that sets in after 10 Rep....is that muscular weakness or the disc compression?????
Ortho wants her to go for a surgery
Regards S
sana

[sdkashif]

Management of the Disc lesions involve a comprehensive treatment strategies following careful assessment of the patient and idetifying his needs.

Physical modalities:

They should be used to reduce pain only in the acute phase. Once past the acute phase, modalities are used sparingly on an as-needed basis.

Superficial heat modalities relax muscle and relieve soft tissue pain.

Conversely, deep-heating modalities (eg, ultrasound) should be avoided in acute cervical radiculopathy since they augment inflammation and, consequently, exacerbate radicular pain and nerve root injury.

Traction:

Cervical traction may relieve radicular pain from nerve root compression. Traction does not improve soft tissue injury pain. Hot packs, massage, and/or electrical stimulation should be applied prior to traction to relieve pain and relax muscles.

Traction has effects of mechanical elongation of spine, facet joint mobilization, promoting muscle relaxation, reduction of pain. Traction is indicated for spinal nerve root impingement, hypomobility of joints from dysfunction or degenerative changes, joint pain from symptomatic facet joints, muscle spasm or guarding, meniscoid blocking, discogenic pain, post compression fracture.

Continuous or prolonged traction is an effective mode of therapy. In it a static traction force is applied for several hours to several days usually in bed. Only small amount of weight is tolerable.

The effective force is influenced by the body position, weight of the part, friction of the treatment table, method of traction used and the equipment itself.

The traction regimens include heavy weight-intermittent or light weight-continuous. The neck is flexed 15-20° (ie, not extended) during traction. In the cervical spine, approximately 10 lb of force is necessary to counter gravity and 25 lb of force is necessary to achieve separation of the posterior vertebral segments. Generally for vertebral separation, in cervical spine, under friction free circumstances a force of approximately 7 percent of the total body weight separates the vertebrae. A minimum force of 11.25 to 13.5KG (25 to 30 lb) is necessary to lift the weight of head when sitting and to counteract the resistance of muscle tension. The greatest amount of separation occurs during the first few minutes of treatment at a given force. To avoid treatment soreness, the first treatment should not exceed 10 to 15 lb. Muscle relaxation can be achieved at levels less than those needed for mechanical separation (4.5 to 6.75KG, or 10 to 15 lb) in the cervical spine. Progression of dosage at succeeding treatment will depend upon the goals and patient reactions.

Light weight-continuous home traction is cost effective and provides the patient more autonomy.

Pneumatic traction devices afford greater patient comfort and, consequently, increased compliance.

See Cervical traction

Collars:

They can be worn during certain activities, such as sleeping or driving, for longer periods.

Although not used commonly, a Philadelphia collar can be worn at night to position the neck rigidly in flexion, thereby maintaining open foramina.

A soft cervical collar is recommended only for acute soft tissue neck injuries and for short periods of time (ie, not to exceed 3-4 days' continuous use). Risks include limiting cervical ROM and losing neck strength if the collar is worn continuously for longer periods.

When worn for radiculopathy caused by foraminal stenosis, the wide part of the collar is placed posteriorly and the thin part anteriorly to promote neck flexion, discourage extension, and open the intervertebral foramina.

See Cervical Collars

Spinal manipulation and mobilization:

It may restore normal ROM and decrease pain; however, no clear therapeutic mechanism of action is known. Some believe that zygapophysial joint adjustment improves afferent signals from mechanoreceptors to peripheral and central nervous systems.

Normalization of afferent impulses improves muscle tone, decreases muscle guarding, and promotes more effective local tissue metabolism. These physiologic modifications subsequently improve ROM and pain reduction.

No evidence exists that manipulation confers long-term benefit, improves chronic conditions, or alters the natural course of the disorder.

Spinal manipulation: Its safety is uncertain

Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity.

Influence of a cervical mobilization technique on respiratory and cardiovascular function.

Cervicothoracic stabilization:

It limits pain, maximizes function, and prevents further injury. Such stabilization includes cervical spine flexibility, postural training, and strengthening. This program emphasizes patient responsibility through active participation.

Restoring flexibility prevents further repetitive microtrauma from poor movement patterning. Pain-free ROM is determined by placing the cervical spine in positions that produce and relieve symptoms. Initially, stabilization commences within established pain-free ROM and then progresses outside this ROM as pain diminishes. Soft tissue or joint restriction inhibiting ROM is treated quickly. Anterior and posterior neck muscles are stretched. Indeed, such spine and soft tissue mobilization, passive ROM, self-stretching, and correct posturing collectively restore ROM.

Postural training commences with the patient, supervised by a therapist, in front of a mirror. The patient performs various transfer maneuvers while maintaining a neutral spine (ie, correct posturing) with feedback from the mirror and the therapist. Patient goals include maintenance of neutral spine and demonstrating correct posture during daily activities.

These proprioceptive skills, implemented during strengthening exercises, facilitate stable, safe, and pain-free cervical posture during strenuous activity. Indeed, cervicothoracic stabilization requires strengthening and coordination of neck, shoulder, and scapular muscles. Cervical muscles include extensors, flexors, rectus capitis anterior, rectus capitis lateralis, longissimus cervicis, and longissimus capitis. Primary thoracic stabilizers include abdominals, lumbar paraspinal extensors, and latissimus dorsi. Scapular muscles include the middle and lower trapezius, serratus anterior, and rhomboids. Chest muscles include the pectoralis major and minor. Successful stabilization also requires the training of the lumbar spine and lower extremities, which provide a foundation for the cervicothoracic spine.

Stabilization exercises proceed systematically from simple to complex. Isometric and isotonic resistive exercises employ elastic bands, weight machines, and free weights. Such conditioning distributes forces away from the cervical spine. Exercise repetition ultimately encodes an engram that commands immediate, automatic cervicothoracic stabilization during everyday activity.

Neuro Moblizations:

Butler's therapy techniques treat radicular symptoms by mobilizing the involved nerve. First, the therapist identifies "adverse neural tension," defined as pathological mechanical and physiological responses elicited from a nerve when its stretch properties and ROM are evaluated. Specifically, the therapist performs neurodynamic testing to evaluate a nerve's mechanical properties (eg, its mobilization around neighboring intervertebral discs) and physiological characteristics (eg, its response to ischemia, inflammation). Having tested the nerve in question, the therapist then may institute treatment consisting initially of passive mobilization to provide CNS input without inciting a stress response and neurogenic massage to reduce perineural swelling. Later, the therapist progresses to active neuromobilization because, according to Butler, recovering nervous tissue (like other connective tissue) requires movement to promote healing and restoration of optimum mechanical properties.

Limited evidence suggests that neurodynamic mobilization improves clinical outcomes. However, optimizing tissue health and cardiovascular fitness, as well as minimizing negative beliefs and environmental factors, can be beneficial.

Functional Restoration:

Functional restoration programs assist patients disabled by chronic cervical pain overcome obstacles to recovery. Such obstacles include deconditioning, secondary gain, poor motivation, and psychopathology

The McKenzie system:

The McKenzie system identifies 3 mechanical syndromes that cause pain and compromise function. The postural syndrome provokes pain when normal soft tissues are loaded statically at end range of motion (ROM); pathology need not be present. Treatment aims to correct posture. The dysfunction syndrome produces pain when the patient, upon attempting full movement, mechanically deforms contracted scarred soft tissue. Consequently, therapy involves stretching and remodeling of such contracted tissue. The derangement syndrome produces intermittent pain when certain movements or postures occur. Specifically, pain may become centralized or peripheralized because of theoretical activity-dependent displacement of intradiscal material. Therapy attempts to correct derangement by promoting activity that centralizes pain.

The McKenzie theory recognizes that, although patients may demonstrate similar signs and symptoms, one movement (eg, cervical extension) nevertheless may help some patients and aggravate symptoms in others. Indeed, McKenzie therapy does not use only extension-biased exercise. Consequently, treatment individualization and patient education play key roles.

See McKenzie Method

Aerobic Connditioning:

It also plays a role in reduction of Pain.

[dfadc2b]

better yet...refer to a chiropractor!

[somasimple]

better yet...refer to a chiropractor!

just no! I do not think that a chiropractor may help anyway.

[aroun2000]

Hi

WHile giving stimulation see to that u do not stimulate any cervicothoracic muslces bcas she is already having disc lesion. U can stimulate muslces of shoulder. Also see if continous traction will be helpful to ur patient.

regards

[email protected]

[alophysio]

In response to Sanagupta's question...

I think the lack of endurance is due to poor motor control.

Once you start training the patient with perfect posture and joint movement (no compensations), you will build their endurance up...

[sanagupta]

Hello!
Thanx for everybody's response.I met the patient today after 3 months she is doing fine with no neurological or muscular weakness
Regards
Sana

[neurospast]

I thank Sdkashif for his list of modalities which could be used and their effects. I would like to make a remark. Superficial heat, in this I suppose, heatpacks seems to me not a very good idea because the inflamation is at least in the cervical area so near the skin that it might well effect the inflammation. One has also to consider that superficial heat will cause a drain of blood from underlying tissue in order to cool the skin. This might effect in an increase of fluid in the effected area which normally would be drained by circulation (which is increased in the skin). Wouldn't it be more favourable to use cold instead of heat in an acute inflamation?