Wednesday, August 17, 2011

C6-C7 syndrome: My clinical experience & suggestions




Many confuse marked tenderness at the coracoid tip, lateral pectoral and medial elbow sites to be a variant of fibromyalgia however usually it comes along with tenderness at the C6-7 level in the cervical spine. A close look in to the history reveals in this group of patients lose tenderness at C5-6 and standard upper body sites with proper neck support during sleep, but remained symptomatic at coracoid tip, lateral pectoral, medial elbow and C6-C7.

Smythe HA (1994) have supported that mechanical factors determine patterns of symptoms and tenderness in this group. This implies that we are talking of segmental referred pain or referred tenderness rather than a pathologically ill-defined spectrum called “fibromyalgia”. If we differ on this front our treatment strategy is mislead. That’s why centrally acting medications or behavioral modifications are equally disappointing outcomes. To add to that tricyclic medications, stretch and spray or trigger point injections may be simply out of wrong terminology assigned to such a clinical entity.

Cyriax in his classical text book of orthopaedic medicine has elaborated how we get pain out of C6-C7 region & wry neck which is clinically better defined than the C6-C7 syndrome as we are talking of. We sleep 70% of our night in side lying positions. Most of the neck supports reach maximum up to caudal surface of vertebral body however with most we can reach adequately C5. Because of this C6-C7 segments sags towards the side on which we sleep with side flexion we also get a coupled rotation at the same site. That’s why people with Discogenic wry neck there is side-bend to the opposite side (same side bending is difficult) & restriction of the rotation to the painful side. However if there is strain to the facet joint structures we may get a pattern side-bend to the same side (opposite side bending is difficult) & restriction of the rotation to the non-painful side.

Physical strategies that have been helpful in such cases as far as my experience go is as follows:
1. Electro-analgesics: Pain reliving modalities in electrotherapy
2. Manual therapy:
Maitland: transverse glide to C6-C7 on the painful side progressing to central PA of C6- may be up to T2 as per the condition.
Mulligan: SNAGs to C6-C7 facets or spine as per the condition
McKenzie: Chin retraction (Chin tucking) with or without extension
Soft tissue therapy: I have found B/L rhomboids stretch to be very effective with digital ischemic pressures to tender points
Neural mobilization: As symptoms abate add neural mobilization program

N:B In my opinion C6-C7 syndrome is a mechanical derangement of minor grade due to repetitive positioning such as side lying.

Reference:

1. Smythe HA; J Rheumatol. 1994 Aug;21(8):1520-6. (The C6-7 syndrome--clinical features and treatment response).
2. Walker JM, Helewa A (Physical therapy in arthritis): WB sounders & Company