1c - CSpine Dx Flashcards
what are 2 dx that fall under the neck pain w mobility deficits category
facet dysfunction
cervical spondylosis/DJD
what dx falls under neck pain with radiating pain
cervical radiculopathy
- intervertebral disc herniation
- DJD
what care does every pt w neck pain receive
multimodal care
- pt ed
- exercise
- manual therapy
what is the significance of neck pain CPG classifications
tells us how to prioritize treatments
certain paths associated with each category
what are 3 common sx of neck pain w mobility deficits
- central and/or unilateral neck pain
- limitation in neck motion that consistently reproduces sx
- associated (referred) shoulder girdle or UE pain may be present
referred pain vs radicular pain
referred pain
- pain is felt in distal tissues from location
radicular pain
- radiating along course of nerve
- narrow band close to dermatome of what nerve supplies
what is the C2-3 facet joint referred pain pattern
L back of skull, L upper back of neck (behind ear)
what is the C3-4 facet joint referred pain pattern
R back of neck
what is the C4-5 facet joint referred pain pattern
L back of neck over upper trap area
- some overlap w C2-3 referred region
what is the C5-6 facet joint referred pain pattern
R low back of neck over shoulder to delt and upper scap area
- some overlap with C3-4 area
what is the C6-7 facet joint referred pain pattern
L upper-mid back, over shoulder, upper arm, covers majority of scap
- some overlap w C4-5 area
what are expected ROM exam findings in neck pain w mobility deficits
limited cervical ROM
neck pain reproduced at end ranges of AROM and PROM
what are suspected segmental mobility exam findings in neck pain w mobility deficits
restricted cervical and thoracic segmental mobility (PPIVMS and PAIVMS)
intersegmental mobility testing reveals characteristic restriction
how are neck and referred pain reproduced in neck pain with mobility deficits
provocation of involved cervical or upper thoracic segments or cervical musculature
what other deficits might be found in the exam of subacute/chronic neck pain w mobility deficits
cervico-scapulothoracic strength motor control deficits
facet dysfunction (hypomobility) common hx and MOI
<50yo
MOI: onset of unilateral neck pain or locking
- unguarded/awkward movt or position
common sx of facet dysfunction (hypomobility)
localized pain
what tests and measures will be altered in facet dysfunction (hypomobility)
palpation - localized changes
PPIVMS and PAIVMS
- reveal altered segmental mobility patterns
ROM - combined movements restricted
how does a neuro exam present for facet dysfunction (hypomobility
usually normal
what are the 2 main groups of pts w hypomobility
1st: younger pts w MOI from waking up w it or turn head awkwardly
- can palpate where painful/stiff
2nd: older group w DJD, CS, OA
- slow changes over long period of time
how do degenerative changes in the spine present
start in intervertebral discs w osteophyte formation and involvement of adjacent soft tissue structures
what about imaging for DJD/CS/OA is important to consider
clinical signs don’t always correlated w imaging
- neck pain (axial)
- radiculopathy
- myelopathy
pain w hypomobility in younger vs older pts
younger = localized
older = generalized
DJD hx
> 50yo
gradual onset
how does pain present in DJD
generalized chronic neck pain
morning stiffness
- loosen up w movement or hot shower
common posture of DJD pt
forward head posture
inc thoracic kyphosis
what tests and measures will be altered in DJD
ROM - dec
joint play
- generalized hypomobility (not a specific pattern of up or downglides)
palpation
- adaptively shortened tissues
- tender
- inc tissue density
- dec mobility
neuro exam of DJD pt?
no radicular s/sx
CPGs for acute neck pain w mobility deficits
thoracic manip
neck ROM exercises
scap-thoracic and UE strength
may provide cervical manip/mob
CPGs for subacute neck pain w mobility deficits
neck and shoulder girdle endurance exercises
may provide thoracic manip and cervical manip/mob
CPGs for chronic neck pain w mobility deficits
multimodal approach:
1. thoracic manip and cervical manip/mob
2. mixed exercise for cervical/scapulothoracic region:
- NM (coordination, proprioception, postural training)
- stretching
- strengthening
- endurance training
- aerobic conditioning
- cog affective elements
3. dry needling, laser, or intermittent mechanical/manual traction
what should the initial focus be of interventions for neck pain w mobility deficits
joint mob of hypomobile segments in cervical and thoracic
what should be included in the interventions for neck pain w mobility deficits
combo of education, manual therapy, and exercise
what are 5 interventions for neck pain w mobility deficits
joint mobs***
ROM exercises - C and T-spine
- combined movements
postural and ergonomic ed
soft tissue mob
strengthening/endurance program
direct vs indirect treatment mobs for mobility deficits
direct = unilateral PA
- palpate right over facet and downglide
indirect = central PA
- get downglide on both sides
- pt might tolerate better
what neck pain w mobility deficits patient population is mobilization movement esp good with
younger pts w lingering twinge after initial mobilization
common sx of neck pain w radiating pain (4)
- neck pain with narrow band of lancing/burning/electric pain in involved extremity
- nerve root irritation, inflammation, compression
- may have referred pain from IV disc
- UE dermatomal paresthesia or numbness
what is the most common cause of neck pain w radiating pain
cervical disc herniation
- results in inflammation around nerve
location of most common cervical disc herniations
C5-6
C6-7
4 risk factors for a cervical disc herniation
smoking
sedentary lifestyle
poor posture
excessive lifting
what are the most common sources of radiculopathy and why
C7 and C6
inc load at those levels
common pt age for radiculopathy
age 40-50yo
common causes of radiculopathy
herniated nucleus pulposis (HNP)
spondylosis
5 differential dx for radiculopathy
peripheral n. disorders
TOS
brachial plexus disorder
parsonage-turner syndrome (PTS) - brachial neuritis
systemic dz
dx procedures for radiculopathy
radiographs
MRI
EMG and nerve conduction studies
what test has a high specificity w radiculopathy
distraction test
prognosis for radiculopathy and recovery timeline
good
substantial improvements first 4-6mo post onset
complete recovery 2-3yr in 80% of pts
MOI for radiculopathy
insidious or traumatic
radiculopathy pain aggravating factors
worse w coughing or sneezing
- valsalva pressure -> inc interspinal pressure
may refer to scap region
palpation of radiculopathy exam
ms guarding to protect area
not one specific area
how does ROM present in radiculopathy
limited and painful
- not a mechanical restriction
- limited by pain
- will improve w pain dec
what ab repeated motions are important in a radiculopathy exam
does it centralize or peripheralize sx
cervical retraction = centralize
what is included in a neuro exam for a radiculopathy and what are common findings
myotomes/dermatomes/DTRs
- myotomal ms weakness
- sensory/reflex deficits associated w involved nerve roots
what r/i a cervical radiculopathy
r/i by presence of 4 (+) exams from the test item cluster:
(+) spurling A test
- SB and compression
(+) upper limb tension test A
- median n.
(+) cervical distraction test
(+) <60deg cervical rotation toward sx side
with 99% specificity
what r/o a cervical radiculopathy
(-) ULTTA
what are other tests for cervical radiculopathy not included in the Test Item Cluster
valsalva test
shoulder ABD test (badoky sign)
arm squeeze test**
- (+) good to r/i
- (-) good to r/o
what are 3 things that nerves need to be healthy and thrive
blood supply
space
movement
CPGs for acute neck pain w radiating pain
may provide mobilizing and stabilizing exercises, laser, and short-term use of c-collar
when is a soft cervical collar appropriate to use in neck pain w radiating pain
acute radiculopathy
- hot and irritated nerve where every move hurts
- if difficult getting comfortable at night or hurts during certain activities
*not long term
CPGs for chronic neck pain w radiating pain
mechanical intermittent cervical traction combined with stretching/strengthening exercises + cervical and thoracic mob/manip
give pt ed to encourage participation in occupational and exercise activities
what is the initial focus of interventions for neck pain w radiating pain and why
centralize arm pain
- indicates better prognosis
if pain peripheralizing, that is a poor prognostic factor
what are 6 interventions for neck pain w radiating pain
- pt ed
- posture & ergonomics - shoulder girdle elevation or unloading or foraminal opening positions
- cervical traction
- centralization exercises
- manual therapy
- strengthening exercises
what pt pop is the intervention of shoulder girdle elevation appropriate for
for high irritability and very acute patients
what is the goal of cervical traction
unload nerve to give more space and centralize the sx
what is an important pt ed component for centralization interventions
pain may get more intense as moves prox, but this is part of healing process
- should warn pts ab this
what are examples of centralization exercises
retraction = lower cervical ext/upper cervical flexion
- repeated movement
what are manual therapy interventions for neck pain with radiating pain and when is this introduced in POC
cervical spine joint mob
thoracic joint manip/mob
later on in treatment
what strengthening exercises are appropriate for neck pain w radiating pain
deep neck flexor
scapulothoracic ms
what are 3 types of traction
positional
manual
mechanical
what are modes of cervical traction and who are they appropriate for
static
- joint and/or nerve root irritability/severe arm pain
intermittent
- acute joint derangement or pts needing joint mob
what pt pop is manual traction most commonly used with and why
more acute radiculopathy
- more specific
- can get feedback and adjust
- won’t spend a lot of time w traction initially
what position should the pt be in for manual traction
hooklying - take pressure off lower back
elbows flex to take tension off nerve
what are 2 pros to manual traction
more specific
easier to adjust force and neck position
why is head halter over door (a form of mechanical traction) rarely used now
compressing thru TMJ
less relaxed in sitting than in supine
when do you transition from manual to mechanical traction
if pt doing well w manual
- may be more efficient to put them on mechanical traction unit
what are 2 common mechanical traction units used today
sub-occipital grip (Saunders)
pronex pneumatic traction unit
mechanical effects of spinal traction (4)
- distraction/separation of vertebral bodies
- distraction of facet joints
- inc ligamentous tension/stretch joint capsules and tendons and spinal ms
- widening of intervertebral foramen
physiological effects of spinal traction (esp intermittent) - 3
- inc circulation
- mechanoreceptor input
- dec pain
what is the goal of spinal traction
maximum sx reduction and centralization of sx
4 indications of traction
HNP
radiculopathy
DJD
facet/joint hypomobility
5 contraindications of traction
- structural dz
- tumor or infectious
- fx, severe osteoporosis, TB of bone, bone tumors - vascular compromise (ie VBI, cervical vascular disorder)
- any time movement is contraindicated
- fx, recent fusion, ligamentous rupture, evidence of instability - impaired cog function
- claustrophobia
angle of traction force to inc IV space at C1-C5
0-5deg flex
angle of traction force to inc IV space at C5-C7
25-30deg flex
what angle of traction force is needed for facet joint separation and what is an indication for this
24-35deg
DJD, stiff neck
angle of traction force appropriate for HNP and why
0deg flex
flex would further protrude disc post
- could have trouble returning to neutral/ext after bc disc has moved
time on traction for acute conditions and HNP
5-10min
time on traction for non-acute conditions and not HNP
15-30min
minimum force needed for traction
8-10lbs
or 7-10% of pt body wt
what does evidence show for the addition of mechanical traction to exercise in cercial radiculopathy
lower disability and pain, particularly at long term f/u
compared to exercise alone
what is an repeated movements intervention mean
pt controlled repeated AROM movements at end-range or sustained posture
- centralizes pain and diminish peripheral sx
what repeated movements are assessed in a pt exam (4)
retraction
retraction + ext
protraction
flexion
