Complicated Cervical Case

Below is a history from a therapist that doesn’t usually work with this type of population followed by my brainstorms.  I enlisted a consult from Patrick Ward (http://http://optimumsportsperformance.com/blog/) to confirm the potential jump signs of cervical triggers.

Ok, I need some advice on a pt I evaluated. 14 y/o hit the football sled “well sorta with my head” 6 weeks ago.  MRI and CT are WNL cleared by neurology and a peds radiologist. I sent them for an x-ray which had not been done, and referred to orthopod to make sure that we were not missing a spinal fx. Kid shows significant postural alignment deficits in the frontal (Lateral flexion and translation at c4-5) and sagital plane. ( c3-4 facets not opening on flexion, excessive extension at the cervical and lumbar regions where we usually see it, and way too much tsp flexion.) Awful postural stability…no clue that he even has intercostals much less how to use them optimally) His major complaint beyond some stiffness and loss of strength and endurance since sustaining the injury, is dizziness and visual sensitivity to light. He’s been cleared by opthamology and ENT. I know that cervical malalignment can cause vertigo but the light sensitivity? What am I missing? I”d love to get this kid some well distributed spinal mobility and some connnective tissue mobility so we can work on alignment and postural and stability, but my gut says something more is going on. I am only giving you the highlights so if you need more to go on, i know you’lll let me know

6 weeks is a long time, but he may still have a concussion.
These symptoms can’t be ignored even though he has been “cleared.” You know my opinion of doctors, so is it possible he just went to mills that didn’t do a comprehensive workup?

A Jefferson fracture can still be in the mix, so good call with the x-ray. How he got all those tests without an X-Ray is interesting.

Light sensitivity is a cranial nerve, so not likely to be affected by C-spine.

Can you do a quick vestibular eval on him? Foam and Dome?
Standing on 1 leg eyes open.
Then eyes closed.
Then 2 feet on an Airex or foam pad.
Then 1 foot EO on the pad.
Then 1 foot EC.
If he can’t do 10s EO or EC, you go to the pad to rule out vestibular.

I don’t think you would incite a concussion with soft tissue work. And it is also quite possible that a jump sign for an OA trigger point can be the light sensitivity or vertigo perception. If you can light it up with manual therapy, you will have solved it without provoking a potential fracture.
Check things like Splenii and suboccipitals. Sometimes they can have trigger points or just general ischemia that can refer to the eye region cause migraine type problems. such as  the aura that goes along with that like sensitivity to light.  They can do other stuff to the eye as well.  Does he appear cross-eyed?
Also check the scalp. The fascia there can impact the face as well.

Bottom line is that it is probably a combination of all of the above.

Turns out vestibular evaluation was positive.  Apparently he couldn’t balance for 1 second on 2 feet foamand EC.  Further history revealed swimmer’s ear and an infection within 2 weeks of his symptom onset.

  • September 16, 2010

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Rich Pfaff Reply

Charlie,

With the order on the quick vestibular evaluation, I am interested in the placement of two feet on the Airex pad as third down the line. Have you ever encountered someone who was able to execute standing on 1-leg with the eyes closed but had noticeable trouble when standing on the airex pad or foam?

And with respect to all of those listed, is the main thing looking for differences in time with eyes open vs. eyes closed than the actual duration of any given hold, per se? i.e. Beyond the 10-second mark, a noteworthy result is differences between eyes open and closed vs. identical or nearly identical performance between the conditions, even if the total time is still relatively low overall

Charlie Reply

Rich – You’ll go down the line to breakout for the potential culprit. If there is a good pattern in SLS EC, you wouldn’t move on to the Airex. I wouldn’t expect to see what you described FN SLS EC and then DN DLS EO.

The overall focus of the Single Leg Stance Breakout for vestibular dysfunction is based on the proficiency with increased challenge. Clearing each level is based on keeping the 10s with acceptable sway and symmetry. Also noting that a vestibular problem will never be asymmetrical.

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