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Case studies in cervicothoracic spine function evaluation and treatment of two dancers with mechanical neck pain.

Dancers are exposed to many work-related injuries. The most frequent site of dance injuries is the lower extremities, while only 7% to 12% of injuries involve the neck. (1-5) Due to the low exposure and frequency of reported neck injuries, there is very little research available in the dance medicine literature that describes them. Nonetheless, there are many cervical, thoracic, and upper extremity injuries that dancers may incur as a result of exposure to extreme ranges of motion, repetitive movements, carrying and lifting, upper extremity weight bearing, handling of props, and wearing of heavy head pieces.

Neck Pain

Mechanical neck pain has been defined as pain in the cervicothoracic region that increases with neck motion. (6) There is a high prevalence of neck pain in the general population; in population-based surveys up to 22% of adults were found to suffer from neck pain. (7,8)

The neck is quite delicate. In a study that measured the pressure pain threshold in the spine, the neck was found to be the most sensitive region, protecting important neurovascular structures. (9)

Treatment Strategies

The clinician can use an evidence-based practice model when making clinical decisions for treating dancers with neck pain. It is important to become familiar with recommendations from the literature, interpret the findings, evaluate their appropriateness for each patient, and use clinical reasoning and expertise to optimize delivery of care. (10)

Cervical Spine Mobilization

Direct mobilization to the cervical spine can be an effective intervention for the care of patients with neck disorders. A systematic review supports the use of cervical mobilization combined with exercise for patients with mechanical neck pain (11); Walker and colleagues, (12) for example, showed short- and long-term improvements in pain, disability, and recovery with this treatment. However, some mobilizations, specifically high velocity thrust mobilizations with rotation directly to the cervical spine, present high risk due to the proximity of the vertebral artery supplying blood to the brain. Mechanical compression or excessive stretching of arterial walls can result in stroke. (13)

Cervical and Thoracic Spine and Regional Interdependence

Given the risk involved in cervical spine mobilization, another approach to treating neck pain is to use mobilization techniques directed at the thoracic spine. Recent evidence supports the use of such indirect treatments, (14-17) now generally associated with the concept of "regional interdependence." (18) This phrase refers to impairments in remote body regions that contribute to the patient's primary symptoms of pain. When these remote areas are treated, they may eliminate the symptoms. For example, treating hypomobile segments in the thoracic spine has been found to be successful in patients with mechanical neck pain (14,19,20) with whiplash disorder, (17) cervical radiculopathy, (21,22) complex regional pain syndrome to the upper extremity, (23) and shoulder pain. (24,25)

Clinical Prediction Rule (CPR)

Clinical prediction rules (CPR) are used to determine the probability that patients will have a successful outcome when they satisfy the criteria of the CPR, based on self-report, history, and clinical exam. A CPR was created by Cleland and colleagues (15) to identify patients with neck pain likely to have success with high-velocity thoracic spine mobilization as an intervention. There were six predictor values that include: symptoms less than 30 days, no symptoms distal to the shoulder, no aggravating symptoms when looking up, Fear Avoidance Belief Questionnaire Physical Assessment (FABQPA) score less than 12, decreased upper thoracic kyphosis, and cervical extension range of motion (ROM) less than 30[degrees]. If four to six of these criteria were met, the patient was found to have 93% to 100% success rate with the intervention.

Dancer Posture

While dancers are often noted for having exemplary posture there can be dysfunction in the dancer's spine when the normal spinal curves are altered. Extreme dance movements into thoracic extension, such as backbends and aggressive partnering work through the upper extremities, may cause thoracic segments to become hypomobile. The dancer with this condition will typically have a flexion restriction in a segment of the thoracic spine. (26) Another common postural fault in (primarily ballet) dancers involves a reduction or reversal of the sagittal plane spinal curves, particularly loss of upper-thoracic kyphosis with neutral or extended upper thoracic segments. (5,26) Dancers presenting with typical postural deficits such as decreased thoracic kyphosis and upper quarter pain may well benefit from thoracic mobilizations.

Case Description

For the general population, evidence suggests that neck pain can be reduced with manual treatment to the upper thoracic spine and exercise. The aim of this case study is to screen dancers in two different settings to see if they are appropriate subjects for thoracic mobilization to treat upper quarter pain. It is hypothesized that dancers, as has been seen in the population at large, will benefit from this treatment.

Examination

An initial patient interview was used to screen for the presence of mechanical neck pain, identify painful activities, assess functional requirements, and set appropriate goals. The study criteria for mechanical neck pain were defined as unilateral or bilateral neck pain, discomfort with joint pressure, restriction of segmental movement as determined by static or motion palpation, and lack of neurological or vascular deficits.

The evaluation began with taking a history of the present condition. Questions were asked regarding onset, duration, nature and location of symptoms, aggravating and relieving factors, and previous history of neck pain or injury. A numeric pain rating scale (NPRS) was used for patients to rate their pain on an 11-point scale ranging from 0 = no pain to 10 = worst pain imaginable.

The physical exam, conducted in the outpatient setting, began with a postural assessment. In the sagittal view, the contours of the spine were divided into segments: atlanto-occipital joint, C2-C6, C7-T2, T3-T5, and T6-T10. Normal, diminished, or excessive curves in the cervical and thoracic spine were recorded. (27)

A neurovascular screen assessed deep tendon reflexes, myotomes, and dermatomes of the upper quadrant. Cervical ROM was measured with a goniometer, (28) and length and strength of the upper quarter muscles were assessed. (27) Endurance of the deep cervical flexor muscles was measured with the cranio-cervical flexion test (Fig. 1) (29) as follows: the patient lay supine with a stabilizer pressure biofeedback unit under the suboccipital region that was inflated to 20 mmHg to fill the space of the cervical lordosis. The patient then submaximally flexed the atlanto-occipital (AO) joint, held the contraction for ten seconds, and repeated this ten times. The accessory motion of the cervical and thoracic spine was tested with segmental mobility and posterior to anterior spring testing of C2-T9 over the spinous processes with the patient in the prone position (Fig. 2). The motion was labeled normal, hypomobile, or hypermobile, and it was noted whether mobilization at a segment provoked pain. (30) Motion testing assessed spinal dysfunction by palpating the transverse processes during active flexion and extension of the spine. This motion was labeled according to symmetry of the transverse processes in each position. (31)

Special tests for symptom reproduction include upper limb tension tests (ULTT) for neural adhesions (32) (Fig. 3), Roos for thoracic outlet syndrome, Spurling for cervical radiculopathy and facet joint irritation, neck distraction to decrease pressure on the foramen, and the vertebral basilar artery test (VBAT). (33) The VBAT is a provocation test that can be used to test for vertebrobasilar artery compression and ischemia. In one procedure, with the patient supine, the clinician passively extends and rotates the patient's head for 30 seconds and looks for signs of brain-stem ischemia, such as vertigo, nystagmus, nausea, or sensory disturbances. If there is a positive result, high velocity cervical mobilization and end range rotation should be avoided.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Outcome Measurements

The patient completed two functional outcome measures, the Neck Disability Index (34) and the Neck and Upper Limb Index, (35) and also a Fear Avoidance Belief Questionnaire physical activity subscale (FABQPA). (36) These outcome tools help quantify how painful and limiting the neck pain is with daily activities and, with repeated measures, can track changes that the patient experiences over time.

Case 1: Acute Neck Pain

A 28-year-old male musical theater dancer signed up for onsite physical therapy services with complaint of a stiff neck two hours before curtain call for a Broadway show. He had been in the show for over a year with no history of neck pain. The pain began upon waking after trying new choreography the previous day to understudy a role that involved thrashing movements of the head. The patient's goals were to decrease pain, increase mobility of his neck, and be able to perform during that evening's performance without limitation.

[FIGURE 3 OMITTED]

His NPRS was 8/10 pain and was described as tightness in the muscles and difficulty moving the head. There was no associated dizziness, blurred vision, or nausea. On postural observation he had left cervical muscle hypertrophy, kyphosis at the cervicothoracic junction, and hypokyphosis in his upper thorax spine. Cervical active ROM was guarded and stiff. Passive rotation was 20[degrees] to the left and 60[degrees] to the right. He had pain with cervical extension to 20[degrees]. Thoracic movement was painful, with reduced flexion occurring below the mid-thoracic spine. There was a positive Spurling test, reproducing neck pain in extension and extension with left sidebending. He had intact dermatome, myotome, and deep tendon reflex distribution from C5-T1, and a negative VBAT within the available ROM. Spring tests and segmental mobility tests of the cervical spine could not be tolerated secondary to the acute nature of pain, but he had stiffness in the T3-T5 spinous processes. With motion testing the thoracic spine had a flexion dysfunction to the right side and was limited in extension, left sidebending, and rotation at T4. There was hypertonicity in the left upper trapezius, which was taut and painful to palpation (Table 1).

Interventions

Therapy was scheduled in 20-minute sessions for evaluation and treatment backstage before the show. The information collected during this short session indicated that this was a musculoskeletal problem. The patient was diagnosed with mechanical neck pain and neck muscle spasms, so a physical therapy treatment could be initiated.

Based on the CPR, (15) this patient was classified as a good candidate for thoracic mobilization; he had four out of six variables, which corresponds to a 93% chance of a successful outcome. The dancer had symptoms for less than 30 days, no symptoms distal to the shoulder, diminished upper thoracic kyphosis, and cervical extension ROM less than 30[degrees]. Due to short treatment time in the backstage setting, he did not fill out a FABQPA score, but it was known that he performed highly physical dancing eight shows each week and would therefore likely have a low score. It was determined that thoracic mobilization would be well tolerated by the patient.

Treatment began with gentle soft tissue work to reduce muscle spasms around the neck. A muscle energy technique at T4 was used to mobilize the thoracic spine. This technique involves extending, left rotating, and left sidebending the upper thoracic spine to the T4-T5 segment.

The position was held for five seconds and released three times, each time bringing him further into the motion. Following the thoracic mobilization, the patient was given active ROM exercises for his neck, ten times in all three cardinal planes of motion.

Results for Case 1

The immediate post-intervention outcome was reduced muscle spasm, as demonstrated by decreased muscle hypertrophy and tenderness and increased left rotation to 40[degrees]. His neck motion was 75% restored, his pain decreased to 2/10, and he was able to do a handstand at the end of his session, a movement that he does in the show. Based on these results, he was given clearance to participate in that evening's performance. At a six-month review of his chart, there was no recurrence of neck pain.

A quick recovery time is important for Broadway performers, who only get paid when they perform. Thus, they are motivated to continue performing in the presence of pain. Additionally, being documented as an injured dancer may affect their ability to get promotions and future work with the production. Without physical therapy intervention, this dancer may have gone through a natural recovery of the condition with some lost days of work, but early treatment likely sped up his recovery.

Case 2: Chronic Neck Pain

A 47-year-old female modern dancer, company director, and choreographer came to physical therapy with complaints of chronic neck pain. She had been dropped from an overhead partnered lift 11 years earlier and landed on her right shoulder. At the time of the injury she had right neck and shoulder pain and could only reach her hand behind her back to the middle of her sacrum. She sought medical attention and had an MRI of her right shoulder, which produced no significant findings. She was told that her neck pain would resolve without intervention.

At her initial evaluation, she had chief complaints of neck pain and limited neck rotation to the right while driving and pain with neck extension to look up and reach a high cabinet. She could not carry a bag, knapsack, groceries, or her guitar; instead, she used a rolling bag with wheels. Her NPRS was 6/10 constant neck pain. She felt better when she put heat on her neck, but was otherwise not able to find relief.

[FIGURE 4 OMITTED]

On postural assessment in the sagittal view, she had a forward head posture with a flexed lower cervical spine and 10[degrees] of AO extension. Her thoracic spine was flexed at T1-T2 and extended at T3-T8 spinal segments. She had muscular tightness in her right levator, pectoralis, sternocleidomastoid, and upper trapezius muscles. Her strength was 5/5 throughout her upper quarter, with the exception of 4/5 bilateral shoulder external rotation. She had a positive Spurling test with extension and right sidebending, a negative VBAT, and a fair craniocervical flexion test (Fig. 1) for deep neck flexor muscle endurance, corresponding to 5 out of 10 10-second contractions. Spring tests between T2-T4 spinous processes (Fig. 2) were painful and stiff, and on motion testing she was unable to flex, rotate, and sidebend the T4 segment to the right. She had a normal response to light and sharp touch from C5-T1 dermatomes bilaterally, with intact deep tendon reflexes and myotomes along the same levels. Her ROM was 50[degrees] of pain-free left rotation and 25[degrees] of right rotation with pain at end range. She could flex her neck to 40[degrees], and extend to 25[degrees] with sharp pain at end-range. Neurodynamic testing using the ULTT was positive bilaterally along the median and ulnar nerve distribution (Fig. 3).

[FIGURE 5 OMITTED]

The patient was cleared of neurovascular injury and diagnosed with chronic mechanical neck pain. Physical therapy goals were to decrease constant pain, restore cervical ROM, improve resting posture of the AO joint, relieve neural tension, and restore her ability to carry a bag, reach and look overhead, and drive a car. The plan for this patient was to see her one to two sessions per week for one month, with treatment to include cervicothoracic mobilization, soft tissue work, stretches, cervicothoracic ROM, cervical stabilization, and muscle endurance exercises.

Interventions

Based on the CPR, this patient was considered a good candidate for thoracic mobilization. The dancer had no symptoms distal to the shoulder, diminished upper thoracic spine kyphosis, cervical extension ROM less than 30[degrees], and a FABQPA less than 12. She met 4 out of 6 variables in the CPR. This corresponds to a 93% probability of successful outcome with thoracic mobilization. (15)

The first treatment addressed motion dysfunction in her thoracic spine. A muscle energy technique was used to treat her T4 flexion restriction, or lack of ability to flex, rotate, and sidebend the T4 vertebral segment to the right. After the T4-T5 segment was localized and moved into the motion restriction, the patient was asked to resist flexion, right rotation, and right sidebend at T4 for 5 seconds, three times, bringing her further into the barrier of movement each time (Fig. 4). After this thoracic mobilization treatment, the patient was reassessed. There was less pain on T1 and T2 spring tests. The cervical spine rotation improved bilaterally to 52[degrees] right rotation with a painful end range and 60[degrees] left rotation. She had improved mobility on her median nerve tension test bilaterally before the onset of pain. An exercise program was prescribed after her first session consisting of gentle chin tucks to restore a neutral AO head position, aiming for 10[degrees] of flexion. The patient held the chin tuck 10 seconds for 10 repetitions.

During the second session, she received the same mobilization treatment, and a cervical spine stabilization program was introduced. This included submaximal AO neck flexion (10 seconds holding for 10 repetitions), active ROM rotation bilaterally, self median nerve neural glide mobilizations, and cervical stabilization with a small ball behind her head while the arms moved through port-de-bras (Fig. 5).

Results for Case 2

By the sixth treatment over the course of one month, the dancer met all of her goals and was discharged from physical therapy. Her neck was pain-free and she had restored symmetrical cervical spine ROM rotation to 60[degrees] bilaterally, negative median and ulnar nerve ULTT, no pain on spring tests from C7-T5, and no tightness in her right SCM, levator, and upper trapezius muscles. She was able to carry her knapsack and guitar, and returned to driving without restriction. Her neck disability index went from 12% to 4%, and her Neck and Upper Limb Index from 27% to 4%. When contacted at six month follow-up, she remained pain-free and had returned to all activities of daily living.

[FIGURE 6 OMITTED]

Discussion

Cervical spine injuries are prevalent in the general population. The treatment recommendations are well documented in the literature, but their application to dancers with mechanical neck pain is lacking. Despite the infrequent reporting of neck pain in the dance population, the condition may be more common than indicated; in the investigator's experience some dancers do not have their neck pain evaluated by a medical practitioner but rather find alternative treatments. They may also simply choose to continue living and performing with varying levels of chronic neck pain.

The purpose of this case report is to describe the physical therapy management of two dancers with acute and chronic neck pain who were assessed and treated in different settings. The patient with acute neck pain was seen backstage at the theater, where performers receive onsite physical therapy for quick evaluations and treatments. The patient with chronic neck pain was seen in an outpatient physical therapy practice. Both dancers had limited cervical ROM, positive ULTT, and stiffness in the thoracic spine. They had participation restrictions in the activities of daily living and in their dance careers. These conditions improved both immediately and long term with upper thoracic mobilization and exercise. This result is consistent with findings for the general population.

Choosing Mobilization Techniques

Choosing the most effective mobilization technique can be a challenge. Various approaches are likely to be helpful, but as with most manual techniques, there is currently little data to support the treatments we use. (37) It may be hard to quantify our manual techniques and control variables, as we rarely use techniques in isolation but rather in combination with other modalities. For now, we will likely choose those techniques that have given us the best outcomes in our practice.

Direct cervical mobilization is a valid approach, but as indicated previously, the decision to use a thrust technique on the cervical spine must be weighed in terms of the risks and benefits. In acute cases, as in the first case reported here, when the cervical spine is sensitive and inflamed, direct treatment to the cervical spine may not be tolerated. Using thoracic spine mobilization as a treatment in such cases can be effective in achieving therapeutic benefits and may avoid the risk associated with cervical spine mobilizations. (14) There are many other passive mobilization treatment techniques that can be used, such as localized graded mobilization (Fig. 2). High velocity mobilizations, for example, have been effective, and it is not necessary to identify the exact spinal level to be treated as long as the segment has been found by the clinician to be hypomobile on a spring test (Fig. 6). (15,31,38,39) An audible or palpable pop is also not essential for good outcomes. (16) This investigator chose to use a muscle energy technique (MET) mobilization because it is gentle and safe, and the patient participates actively in the treatment by moving through the joint restriction (Fig. 4).

Relationship Between Thoracic Pain, Stiffness, and Neck Pain

There are several proposed explanations for why the upper thoracic spine may be stiff, palpating these segments may reproduce local and regional pain, and treating the thoracic spine may reduce symptoms of neck pain.

Tenderness in the upper thoracic spine is not a normal finding in asymptomatic adults and can be a sign of regional dysfunction. (9) Normal curves distribute forces evenly throughout the spine and minimize the concentration of load in a particular region. (40) With thoracic hypomobility, pain is often not at the site of stiffness, but can produce compensatory changes above or below the affected segment in the more mobile cervical or lumbar spine. (40)

Stiffness and tenderness in the upper thoracic spine may result from a prolonged postural fault. It can present in occupations involving forward stooping or flexed postures, as in the sedentary seated position of office workers, (41) or from a chronically rigid extended upper thorax spine, as in some ballet dancers. (26) This stiffness can cause mechanical compression of cutaneous nerves on the skin overlaying the spinous processes. Based on a cadaveric dissection, the cutaneous spinal nerves from T1-T5 travel through the erector spinae muscle and become superficial, reaching the apex of the spinous process of the same vertebrae and innervating the skin. (42) If these cutaneous nerves in the thoracic spine become irritated they may be painful to pressure.

The lack of movement (stiffness) in the upper thorax spine can also cause poor blood flow and create relative ischemia to the area. This may irritate nociceptors in the synovial joint capsule of the thoracic vertebrae (43) or cause neighboring sympathetic nerves to vasoconstrict local arterioles and capillaries. This may also provoke nerve roots of the sympathetic trunk that originate at T1-T4 and travel up to the head to present as symptoms of neck pain. (44)

In the two dance cases described here, as there was immediate relief of neck pain, muscle guarding, improved ROM, and decreased neural tension after thoracic mobilizations, there is likely an association between the thoracic facet joints and the pain pattern into the neck. The mobilization may reduce ischemia and mechanical compression of the hypomobile thoracic spinal segments and the sympathetic nervous system. This may account for all of the beneficial effects experienced by the two dancers.

Conclusion

In this case report, two dancers had a rapid return to activity after treatment with thoracic mobilization and exercise for their neck pain. These positive results support the hypothesis that thoracic mobilization combined with exercise was an effective treatment for restoring the rigorous physical requirements of two dancers at the acute and chronic stages of a neck injury. It is concluded that clinicians should consider including evaluation and treatment of the thoracic spine when treating dancers with neck injuries.

Limitations

This was a descriptive case study and not an experimental study, where variables from the environment are controlled. Given the small number of cases in this study, it is hard to generalize the findings to other dancers with similar problems. There is a scarcity of literature available on cervical pain in dancers, and more research is needed to understand the incidence, prevalence, and control of this condition. To improve the validity of this investigation future research should utilize a larger sample of dancers and a controlled intervention.

Caption: Figure 1 Craniocervical flexion test using the Stabilizer Pressure Biofeedback unit.

Caption: Figure 2 Spring test on the spinous processes; can also be used as a graded mobilization technique.

Caption: Figure 3 Upper Limb Tension Test (ULTT) of the median nerve.

Caption: Figure 4 Muscle Energy Technique (MET): one of many positions to mobilize the upper thoracic spine in flexion, rotation, sidebending to the right side.

Caption: Figure 5 Upper quarter functional retraining with neck stabilization; port de bras of arms, with ball behind her head.

Caption: Figure 6 High velocity upper thoracic mobilization.

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Emily Sandow, P.T., D.P.T., is a clinical specialist and physical therapist at the Harkness Center for Dance Injuries, NYU Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York.

Correspondence: Emily Sandow, P.T., D.P.T., Harkness Center for Dance Injuries, NYU Hospital for Joint Diseases, NYU Langone Medical Center, 301 East 17th Street, New York, New York 10003; emily.sandow@nyumc.org.
Table 1 Physical Findings, Impairments, Interventions, and Outcomes

                              Subject 1: Acute Neck Pain
Variable                      At IE                 At Discharge

Age                           28
Gender                        Male
PT Setting                    Onsite backstage PT
Duration of symptoms          1 day
Number of treatments          1
Numeric pain rating scale     8/10                  2/10
Cervical ROM
  Flexion                     50                    50
  Extension                   20                    25
  Sidebending Left            45                    45
  Sidebending Right           45                    45
  Rotation Left               20 painful            45 painful
  Rotation Right              60                    60
Neurodynamic Test             N/A                   N/A

Dermatome                     Intact                Intact
Myotome                       Intact                Intact
UQ strength
Craniocervical Flexion Test   Good                  Good
Spring Test                   Hypomobile T3-T5      Normal T3-5

Motion Test                   T4 FRS Right          Negative
Spurling Test                 + ext/ Left SB        + ext/Left SB
Distraction Test              Negative              Negative
Neck Disability Index         N/A                   N/A
Neck and Upper Limb           N/A                   N/A
Index
FABQPA                        N/A                   N/A
VBAT                          Negative              Negative

                              Subject 2: Chronic Neck Pain
Variable                      At IE

Age                           44
Gender                        Female
PT Setting                    Outpatient PT office
Duration of symptoms          11 years
Number of treatments          6
Numeric pain rating scale     6/10
Cervical ROM
  Flexion                     40
  Extension                   25 painful
  Sidebending Left            30
  Sidebending Right           30
  Rotation Left               50 deg painful
  Rotation Right              25 deg painful
Neurodynamic Test             +ULTT median and
                              ulnar nerve
Dermatome                     Intact
Myotome                       Intact
UQ strength
Craniocervical Flexion Test   Fair
Spring Test                   T1 and T2 sensitive,
                              T4 hypomobile
Motion Test                   T4 ERS Left
Spurling Test                 + ext with R SB
Distraction Test              Positive
Neck Disability Index         12%
Neck and Upper Limb           27%
Index
FABQPA                        9
VBAT                          Negative

Variable                      At Discharge

Age
Gender
PT Setting
Duration of symptoms
Number of treatments
Numeric pain rating scale     0/10
Cervical ROM
  Flexion                     N/A
  Extension                   N/A
  Sidebending Left            N/A
  Sidebending Right           N/A
  Rotation Left               60[degrees]
  Rotation Right              60[degrees]
Neurodynamic Test             - ULTT

Dermatome                     Intact
Myotome                       Intact
UQ strength
Craniocervical Flexion Test   Normal
Spring Test                   Painfree and restored
                              mobility C7-T5
Motion Test                   Negative
Spurling Test                 +ext with R SB
Distraction Test              Positive
Neck Disability Index         4%
Neck and Upper Limb           4%
Index
FABQPA                        0
VBAT                          Negative

UQ: upper quarter; FABQPA: fear avoidance belief questionnaire
physical assessment; IE: initial evaluation; ULTT: upper limb tension
test; ERS: extension rotation and sidebending.
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Title Annotation:On-Site Physical Therapy
Author:Sandow, Emily
Publication:Journal of Dance Medicine & Science
Date:Jan 1, 2011
Words:5617
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