Hi everyone, here's a follow-up to the patient with Parkinsonian tremor who has returned with vertigo-like symptoms.

RECAP:

72-year-old male with a 9-month history of "Parkinsonian tremor" right-sided that responded to cervical spine mechanical repeated movements and remained better. He then returned a few months later with vertigo-like symptoms. All vestibular testing was negative. Positive ataxia with tandem. Single-leg stand for less than 5 seconds each. Strength was good. Hoffmans normal. Had to lean on the wall or hand on wife's shoulder to walk. Had paresthesias of face and bilat thighs. Vision was blurred, double at times. Sustained retraction and sustained upper TH extension supine over #1 soccer ball improved multiple baselines.

MRI Results

Disc space heights: Preserved

C1-2: Unremarkable.

C2-3: No significant disc herniation, foraminal stenosis or spinal canal stenosis.

C3-4: Mild disc bulge. Right uncovertebral degenerative changes. Moderate bilateral facet arthropathy. Moderate left foraminal stenosis. Severe right foraminal stenosis. No central canal stenosis.

C4-5: No disc herniation. Severe right facet arthropathy and mild left facet arthropathy. Moderate left foraminal stenosis. Severe right foraminal stenosis. No central canal stenosis.

C5-6: Mild disc bulge. Moderate bilateral facet arthropathy. Moderate-severe bilateral foraminal stenosis. No central canal stenosis.

C6-7: Mild disc bulge. Severe right and moderate-severe left foraminal stenosis. No central canal stenosis.

C7-T1: No significant disc herniation, foraminal stenosis or spinal canal stenosis.

IMPRESSION:

• No acute osseous injury of the cervical spine.
• Cervical spine spondylosis as described above.

FOLLOW-UP:

Noticeable improvements. Sustained upper-TH ext over the ball is most helpful. Able to roll in bed and able to close eyes in the shower and wash hair without a problem. Vision is clear. Still has some difficulty knowing where his feet are in space, but has improved as well. When he is bending, he sometimes loses his balance forward.

I maintained upper thoracic extension sustained over a ball (see the video below) and added one activation exercise (see the video below). He is going in the right direction, and I want to maintain this momentum without pushing too far.

EXAM:

Walking: independent without need for UE support (Improved)

Cervical AROM: Baseline: zero symptoms at rest (Improved)

Flexion: chin to chest, NE (Improved)

Extension: 90-90, NE (Improved)

Rotation R: 80, NE

Rotation L: 80, NE

Lateral Flexion R: 20-30, NE

Lateral Flexion L: 20-30, NE

Strength: 5/5 throughout UEs

DTRS: unchanged

Sensation: both cheekbones and bilateral outer thighs feel normal (Improved)

Tandem: Normal (Improved)

Hoffman (UMN): negative bilat

SLS: ~15 seconds each with LOB (Improved)

TAKE-AWAY:

A spinal mechanical contribution persists and he relapsed due to persistent forward head positioning. He has improved in multiple baselines in a short period of time. He has already had a cervical MRI and has remaining neurology work-up. He improved significantly with mechanical treatment, so I'm cautiously sticking with it.

Until next time,

Ryan Tauzell, PT, Cert. MDT

ryan@atlashealth.io

​atlashealth.io​

PS: As always, I'm happy to chat about these patients. I've enjoyed sharing, and thanks so much for your emails!

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