Study Design: Case series. Objective: To describe the management of 7 patients with grade 1 cervical compressive myelopathy attributed to herniated disc using intermittent cervical traction and manipulation of the thoracic spine. Background: Intermittent cervical traction has been indicated for the treatment of patients with herniated disc and has been suggested to be helpful for patients with cervical compressive myelopathy. Manipulation of the thoracic spine has been utilized to safely improve active range of motion and decrease pain in patients with neck pain. Methods and Measures: Seven women with neck pain, 35 to 45 years of age, were identified as having signs and symptoms consistent with grade 1 cervical compressive myelopathy. Symptom duration ranged from less than 1 week to 52 weeks. All patients were treated with intermittent cervical traction and thoracic manipulation for a median of 9 sessions (range, 2-12 sessions) over a median of 56 days (range, 14-146 days). Numeric Pain Rating Scale and Functional Rating Index scores served as the primary outcome measures. Results: The median decrease in pain scores was 5 (range, 2-8) from a baseline of 6 (range, 4-8), and median improvement in Functional Rating Index scores was 26% (range, 10%-50%) from a baseline of 44% (range, 35%-71%). Dizziness was eliminated in 3 out of 4 patients and chronic headache symptoms were improved in 3 out of 3 patients. There were no adverse events or outcomes. Conclusions: Intermittent cervical traction and manipulation of the thoracic spine seem useful for the reduction of pain scores and level of disability in patients with mild cervical compressive myelopathy attributed to herniated disc. A thorough neurological screening exam is recommended prior to mechanical treatment of the cervical spine.

J Orthop Sports Phys Ther. 2004;34(11):701-712. doi:10.2519/jospt.2004.1519

Key Words: conservative, Hoffmann’s reflex, mechanical traction, spinal cord impingement, upper motor neuron

Cervical radiculopathy (CR) is a problem that is frequently encountered by physical therapists. The incidence of CR in the fifth decade of life is 2.03%, approximately 3 times more prevalent than in other age groups. Radiculopathy is defined as any diseased condition of spinal nerve roots. Cervical radiculopathy, or disease to the nerve roots in the cervical spine, is manifested primarily by unilateral motor and sensory symptoms into the upper limb, muscle weakness, sensory alteration, and reflex hypoactivity. Generally, onset of CR is insidious and the most common causes are cervical disc lesions and osteophytic encroachment, which results in nerve root or spinal nerve impingement or inflammation. The purpose of this resident's case problem is to demonstrate the dynamics of the diagnostic process in determining the appropriate treatment for a patient with CR. Treatment selection and progression will use the treatment algorithm proposed by Erhard, combined with the information from history, physical examination findings, and the patient's response to treatment interventions during the course of rehabilitation.

J Orthop Sports Phys Ther. 2000;30(12):745-754.

Key words: cervical spine, nerve roots, rehabilitation

With recent health care policy changes and the implementation of direct access in many states, physical therapists must be able to identify pathology that is beyond their scope of practice. The 5 case reports presented in this series required the differential diagnosis of hip versus lumbar spine pathology. All of the cases required a referral from the physical therapist to either the patient's physician or a specialist because of abnormal screening test results. Each referral resulted in a new diagnosis of pathology that was beyond the scope of physical therapy. Cyriax's concepts of capsular and noncapsular patterns of joint restriction and the "Sign of the Buttock" proved useful in differentiating between hip and lumbar spine pathology in each patient. Our clinical experience indicates that utilizing the presence/absence of a capsular pattern and a "Sign of the Buttock" to screen out hip pathology in patients may be effective; however, further research is needed to support these claims.

J Orthop Sports Phys Ther. 1998;27(4):308-315.

Key Words: hip, lumbar spine, capsular pattern, differential diagnosis

Study Design: Resident’s case problem. Background: The signs and symptoms of cervical radiculopathy (CR) warrant the consideration of several other conditions in CR’s differential diagnosis. One condition that may mimic CR, which is not well known among physical therapists, is Parsonage-Turner syndrome (PTS). PTS is characterized by an onset of intense pain that typically subsides within days to weeks. However, as pain subsides, weakness and/or paralysis may develop in upper extremity muscles. The purpose of this resident’s case problem is to describe a patient who presented to our clinic with a diagnosis of CR, but had findings consistent with PTS. Diagnosis: The patient was a 43-year-old male referred to physical therapy with a diagnosis of CR. He had a previous episode of CR 1 year ago that was treated successfully. He had positive magnetic resonance imaging findings of structural abnormalities suggestive of causative factors for CR. The patient was treated for CR with thoracic and cervical spine manipulations and intermittent cervical traction. The initial acute severe pain subsided, but weakness in the upper extremity worsened. Diagnosis of PTS was made upon exclusion of other potential confounding diagnoses and the findings of fibrillation potentials and positive waves in electrodiagnostic studies. Discussion: CR and PTS are characterized by pain in the cervical spine, shoulder, and upper extremity. CR generally has an insidious onset, while PTS has a rapid onset of intense pain. Symptoms of CR are exacerbated with neck movements, while symptoms related to PTS should not be exacerbated with neck movements. In patients that do not respond to conventional therapy and have a progression of upper extremity muscle weakness, regardless of decreased pain, the diagnosis of PTS should be considered.

J Orthop Sports Phys Ther. 2005;35(10):659-664. doi:10.2519/jospt.2005.2075

Key Words: cervical spine, neck, nerve, upper extremity

Study Design: Resident's case problem. Background: The purpose of this resident's case problem is to describe a 39-year-old female patient with insidious onset of hip pain. This patient had discrete findings on subjective and physical examination that prompted referral for further imaging studies of the left hip and pelvis. Despite having seen multiple providers, no imaging of the involved hip or pelvis had been performed. A prolonged duration of symptoms, severe gait disturbance with an associated Trendelenburg sign, difficulty sleeping, and an empty end feel with passive range of motion increased concern that a pathological process might be present. Diagnosis: Imaging studies revealed a large destructive soft-tissue tumor later found to be non-Hodgkin's lymphoma. Discussion: It is incumbent upon physical therapists to be aware of the potential for severe pathological conditions that mimic musculoskeletal complaints to exist and understand how to identify patients for whom further testing and/or referral may be appropriate. Existing guidelines for low back pain may assist with decision making in the absence of specific guidelines for when to request imaging in patients with nontraumatic hip and pelvis pain. Proficiency in screening for conditions not amenable to physical therapy treatment or that require consultation to other health care professionals is essential to physical therapy practice.

J Orthop Sports Phys Ther. 2005;35(11):738-744. doi:10.2519/jospt.2005.2064

Key Words: cancer, pelvis, physical therapy, radiology, screening