Published by the Medical Journal mechanical diagnosis and treatment of the Hellenic McKenzie Institute: Clinical cases ” therapeutic approach of a patient with Artificial Disk prosthesis (PCM)”, Volume 8 Issue #4 October-December 2009

Lambros S. Hadjimichael, Cert. MTD

Kostas H. came to my physiotherapy center at the beginning of December 2007. Kostas is a football player of the 1st category of the National Team of Cyprus. He had Intervertebral Disc replacement (C– C6, ) with an artificial cervical disc (PCM) on the 26/11/2007.

The artificial cervical disc prosthesis (PCM) is a new method that is based on the evolution of the surgical artificial discs of the lumbar spine and began in 1980. The prosthesis consists of two final plates with chromium-cobalt- alloy which is suitable for implantation. Is a proven biocompatible implantable material Which can be stabilized in the last tail plate where is a second polyethylene plate. The two plates are not mechanically connected, so they can mimic the range of physical movements guided by existing muscles and ligaments. An immediate stabilization of the terminal plates with the corresponding vertebral bodies is achieved through the press-fit implantation method and the 1 mm protrusions for safer placement on the surface of the disc. A special coating on the outer surface of the terminal plate enhances/increases the stabilization and rapid regeneration of the adjacent bone. The tail terminal plate is available in a variety of sizes (height) and the accessories come in different lengths and widths allowing the surgeon to adapt the prosthesis to the anatomy of each patient. The surgical approach used to implant PCM Artificial Cervical Disc prosthesis is the same as conventional spinal fusion. The small surgical incision, decreases patient’s hospital stay.

Figure 1. The procedure (radiographically) of implantation of the artificial PCM disc in the patient K.H.

This incident has intrigued me in applying a McKenzie protocol in an attempt of a therapeutic approach. Initially, this was done by designing points of interest, limitations, contraindications, goals and modifying/ combining the therapeutic protocol of “whiplash” syndrome and dysfunction syndrome. As well as the short- and long-term effect that the patient would have on the implementation of this protocol.

At the beginning, the aim was to pre-operative education before was completed in order to obtain the facts, (pre and post operation), from the neurosurgeon as to the surgical technique and the limitations that existed (preoperative evaluation form).

Points of interest and common principles of “whiplash” and malfunction syndromes:

  1. Surgery can cause reduction of spinal mobility from the contraction of fibrous collagen of scar tissue. The scar tissue is a strong tissue which could form inside or near it healthy surrounding muscle structures causing the decrease of mobility.
  2. It would not be possible to identify the affected surgical structures that caused the pain because each of the soft tissues could be adjusted to shortening so the pain could be due to adaptive shortening of ligaments, through the adjacent vertebral discs, aphasic joints, superficial or deep muscles and their adhesions.
  3. The pain from dysfunction syndrome comes from the mechanical deformation of functionally weakened soft tissue. This abnormal tissue may be the result of previous injury or inflammation or degeneration processes. These processes result in contraction, scarring, symphysis, adaptive shortening or incomplete healing. Pain occurs when this abnormal tissue is charged.

Thus structural changes and scar tissue could affect the mobility of Cervical Spine with painful limitation to the final range of motion in one or more directions.

Points of interest in the various stages of healing:

  1. Each fix is followed by the restoration which is divided into three phases: a. inflammation, b. healing, c. reform (2, 3, 4).
  2. Failure in any of these procedures can lead to incomplete or ineffective healing leading to chronic pathological tissue changes or to recurrent structural insufficiencies.

The pain of soft tissues or movements would exist until the structures are reformed. This can be achieved through a methodical McKenzie exercise program where the tissues would be charged (stage II and III, Table 1) repeated in order to return to full functionality.

Contraindications in the various stages of rehabilitation

  1. Severe muscle pain or spasm,
  2. Infections
  3. Symptoms such as dizziness or other symptoms of vertebral basic insufficiency and
  4. Increasing or peripheral signs and symptoms.

The rehabilitation protocol was designed entirely on the basis of the three stages of healing. Thus the protocol consists of three (3) phases:

  1. Inflammation,
  2. Healing and
  3. Reforming.

Phase of inflammation ( < 5 days)

Points of Interest:

  1. Reducing pain with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs),
  2. Providing patient information on the treatment protocol;
  3. Use of the cervical collar for three days and travel by car for the first 8 weeks.
  4. Assessment of the psychological state of the patient (factors that could adversely affect the patient) (5)

It should be emphasized that a careful approach method was made for the patient so he/she can find it inconvenient and be able to follow. Moreover, the desired result was directly linked to its own cooperation and responsibility.

Healing phase (from 5 days to 3-4 weeks)

Points of Interest:

  1. Initiation of mild active movements in a pain-free range (improved functionality) (Table 1)
  2. In case of pain, movements were performed to the point that was tolerated by the patient,
  3. Tissue trends by applying every 2 hours, 15 repetitions. Mild movements in all directions encourage the transfer of fluids and help to nourish collagen and non-vascular articular structures. They also facilitate the removal of the expiration allowing healing.
  4. The immediate controlled introduction of mild movements is vital at this stage. Repeated movement predisposes the return to functional charging (phase III) ensuring an increase in the strength and functionality of the tissue. (6)

The progressive application of mild movements was based entirely on the patient’s response to movement. (1)

  1. Correction of its posture (15 repetitions / 3 times a day)
  2. Use of orthopedic pillow
  3. Advice to continue his daily activities as much as he can, informing him that inactivity can cause chronic pain. (5)
  4. Encouraging the patient to start a fitness maintenance program (after the 14th day) The program included a static bike, a treadmill (fast walking), swimming (with mask and snorkel), stretching and strengthening exercises of the muscle groups of the lower extremities . During the training the team are monitoring as a simple observer. This program was designed by the physiotherapist and the supervision was done by the team trainer.

Phase of reformation (from 3-4 weeks to …..)

Points of Interest:

  1. Dynamic mechanical assessment of the track gauge,
  2. Start movements with full range,
  3. Improving functionality and
  4. Increase in his activities (at this stage the footballer was encouraged to be active within the limits of his endurance as well as a personalized program of reintegration into his football activity).

 

 Phase IPhase IIPhase III
Motion Track Range PartialFull
Rear traction (under load)6/12/2007 ×15/2h17/12/2007 ×15/2-3h
Rear traction/overextension (under load)8/12/2007 ×15/2h21/12/2007 ×15/2-3h
Rear traction and turning7/12/2007 ×15/2h19/12/2007 ×15/2-3h
Front View6/12/2007 ×15/2h17/12/2007 ×15/2-3h
Rear pull and lateral bending8/12/2007 ×15/2h21/12/2007 ×15/2-3h
Correction of stasis6/12/2007 15/3 times a day15/3 times a day
Πίνακας 1. Αρχές αυχενικών διαδικασιών που ακολούθησε ο ασθενής κατά τις διάφορες φάσεις

 

Figure 2. The moves of Cervical Spine after the rehabilitation program

This case proves that knowledge of the of tissue healing, harmful influences and means that promote good therapeutic results using the McKenzie method are key elements for a physiotherapist. The footballer returned to full athletic activity three months post- surgery. This proves that a major surgery is not always the cause of the removal of athletes from the playing fields. At the same time his case gave me moral satisfaction since the sportswriters were particularly concerned with the problem of this particular athlete and his rapid improvement.

Bibliography / articles

  1. Lance Twomey, PT, PhD – James R. Taylor, MD, PhD.Whiplash syndrome: pathology and physical therapy.
  2. Barlow Y, Willoughby J (1992). Pathophysiology of soft tissue repair. Br Med Bull 48.698-711.
  3. Carrico TJ, Mehrhof AI, Cohen IK(1984). Biology of wound healing. Surg Clinics Nth Am 64.721-733.
  4. Enwemeka CS (1989). Inflammation, cellularity, and fibrillogenesis in regenerating tendon: implications for tendon rehabilitation. Physical Therapy 69.816-825.
  5. Christinakis K (2005). Physiotherapeutic treatment of the accompanying effects of “whip” (TSM). Mechanical Diagnosis and Treatment. Publication of the Hellenic McKenzie Institute Volume 4issue 
  6. Zeuner J, PT, Dip.MDT (2005) The result of mechanical therapy in tissue repair and reform. Mechanical Diagnosis and Treatment. Publication of the Hellenic McKenzie Institute Volume 4issue 
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