Elderly Patient With Neck Pain and Gait Change
A 74-year-old woman presents with 6 weeks of progressive neck stiffness and unsteadiness when walking. She describes her gait as 'shuffling' and has had two near-falls in the past month. She reports intermittent numbness in both hands and occasional clumsiness with buttons. Past history includes well-controlled type 2 diabetes and hypertension. On examination, cervical range of motion is reduced in extension, with pain at end range. Deep tendon reflexes are brisk at the knees and ankles, and there is a positive Hoffmann sign bilaterally. She has no fever, no weight loss, and no bowel or bladder change. She asks for 'a good neck adjustment' because a friend had one that helped.
1. Interpret the examination findings and explain what they imply about the safety of cervical manipulation in this patient.
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The combination of progressive gait unsteadiness, hand clumsiness, bilateral paresthesias, brisk lower-limb reflexes, and a positive Hoffmann sign suggests cervical myelopathy until proven otherwise. Hoffmann sign is a marker of upper motor neuron irritability and, in the context of gait change and hand dexterity loss, is a significant finding. Reduced extension with pain is nonspecific and does not exclude cord compression.
Implications for manipulation:
- Cervical high-velocity thrust is contraindicated in suspected myelopathy because of the risk of cord injury and because the mechanical rationale (restoring segmental motion) does not address the underlying problem.
- The presence of bilateral symptoms and gait involvement raises the level of concern beyond a single-level radicular picture.
- Imaging referral (MRI of the cervical spine) is the appropriate next step before any manual therapy, and urgent referral is warranted if symptoms are rapidly progressive.
Document the neurologic findings, the decision to defer manipulation, and the referral.
2. Outline your management plan, including what manual care, if any, you would provide while awaiting imaging.
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Management should be staged:
- Referral and safety - refer for MRI and neurologic assessment. Provide return precautions for worsening gait, falls, new weakness, or bladder/bowel changes.
- Activity guidance - avoid end-range neck extension and loading; encourage supported, pain-free mobility; address fall risk (home hazards, assistive device assessment).
- Manual care while awaiting imaging - if the patient is comfortable, gentle soft-tissue work and low-load positional release to the cervical and upper thoracic region may reduce muscular guarding. Avoid thrust techniques, sustained end-range extension, and any technique that provokes paresthesias.
- Reassessment - document neurologic status at each visit and stop manual care if symptoms progress.
- Communication - explain to the patient why the 'adjustment' she requested is not appropriate, and what the imaging is intended to clarify.
This plan respects patient goals while prioritizing neurologic safety.