1h - Cspine Rehab and Surgical Flashcards
what is the key intervention for multimodal treatment
education
what is criteria for d/c traction
when pt doesn’t need it anymore bc pain is centralized and don’t have pain in extremities anymore
- could regress to joint mobs and strengthening
what is an important thing to do at the first visit bc “break ups” w pts can be hard
set expectations regarding length of care, pt and PT goals, prognosis, and goal of transition to independence w HEP
what is dc of PT criteria
dc when goals achieved -or- pt not progressing
what are goals to achieve by dc
long term functional outcome
associated impairments (STG)
- functional stability/endurance
- premorbid activity level
- independent HEP
- balanced posture
what are impairments that are still appropriate to dc a patient with
pain 2/10
80% ROM
strength 4/5
why is pt education an important intervention
builds therapeutic alliance
lends to better buy in and adherence to PT exercises
what are things to include in patient education (5)
patient centered care
ed on condition/management options
body mechanics
posture
ergonomics
what are 2 criteria for pts to progress to c spine isometric exercises
good neck control
asymptomatic
what are 4 main categories of exercise interventions for the cspine
- motor control / proprioceptive retraining
- strengthening and endurance exercises, neck and upper quarter
- aerobic conditioning
- functional training
what is the mulligan concept
adjunct to treatment (central and unilateral PAs) in plane of facet in superior direction
- aka mobilization with movement -> apply concurrent accessory motion during active physiologic mvmt to end range
what are the parameters for mulligan treatment and what are the 2 most important ones and why
*P - pain free
*I - instant result
LL - long lasting
if not pain free & no instant result, need to adjust
what are 3 techniques that are part of the mulligan concept
NAGS - natural apophyseal glide
SNAGS - sustained natural apophyseal glides
MWMS - mobs w mvmts
how is SNAGS implemented in the cervico-thoracic spine
pt performs symptomatic mvmt, PT applies SUSTAINED accessory glide during movement
must result in full range pain free mvmt
how are NAGS implemented in the cervico-thoracic spine
OSCILLATIONS that can be applied to facet joints C2 - T3
applied mid to end range
how are MWMs implemented in the cervico-thoracic spine
as spinal mob w limb mvmt
transverse pressure at side of relevant SP as pt moves limb thru previously restricted ROM
what are ms energy techniques
use voluntary ms contractions exerted against precise counter force to inc joint ROM
how does ms energy work according to physiologic principles
joint mob force
post isometric ms relax (autogenic inhibition)
reciprocal inhibition
what is the technique used to ms energy
engage restrictive barrier in all planes (combined mvmt pattern)
provide gentle isometric resistance
hold for 5-10sec
wait for complete relaxation of ms
reposition to engage new barriers
repeat sequence
what is strain-counterstrain
positional release
indirect technique for somatic dysfunction, place body into position of ease, ms in maximally shortened position
who is a strain-counter strain technique good for
pts w pain and guarding in ms
pain w ms contraction
what is the technique for strain-counter strain
locate and palpate tender point while ms is in passively shortened position
- palpate tender point in that position and hold for 90-120sec until feel ms point relax and return to resting position
what are 5 medical interventions for neck pain
pharm
epidural steroid injections
surgery
prolotherapy/regenerative injection therapy
radiofrequency ablation
what are meds that may be used for neck pain
analgesics/NSAIDS
short term opioids
oral steroids
ms relaxants (neuro pain)
what is radiofrequency ablation
(rhizotomy) non surgical, minimally invasive procedure that uses heat to reduce or stop transmission of pain
what is the most sensitive diagnostic imaging that can be used for neck pain
MRI
what are MRIs very sensitive in detecting and what is a consideration of this
soft tissue (ie disc) abnormalities
can see high incidence of abnormalities in asymptomatic pts
when is it appropriate to get an MRI for neck pain
if considering surgery
other than MRI, what are 2 other dx tests that can be done
electrodiagnostic testing
- EMG
- nerve conduction studies
transforaminal vs interlaminar injection
transforaminal
- most common
- more target specific
- more potential complications
interlaminar
- med close to assumed site of path
what is the purpose of injections
to inject a med (ie corticosteroid) around nerve root to dec inflammation
when are injections indicated
not benefiting from traction w arm pain
what is a commonly used med for injections
methylpredisolone
what is part of the procedure for injections
fluoroscopy is used to guide the injection
who may epidural injections be considered for
pts w cervical radiculopathy from degenerative disorders
what is the main patient who will benefit from injections
someone w disc herniation + radiculopathy
what does the evidence say about the the use of epidural injections for pts w chronic neck and UE pain
combo of pharmacotherapy, PT, and epidural may be more effective than either approach individually
what pt is the evidence GOOD for a cervical epidural w local anesthetic and steroids
cervical disc herniation
what does the literature say about the use of local anesthetic vs cervical epidural + local anesthetic + steroids only for cervical disc herniation
fair for use of local anesthetic only
- good for the other
what pts is the evidence fair for use of local anesthetic (w or w/o steroids) - 3
axial or discogenic pain
spinal stenosis
post-surgery syndrome
what is a consideration of the use of epidural injections
potential complications d/t invasive nature
what are 4 indications of surgical intervention being needed
- no improvement w non-surgical treatment in 6-12wks (PT, injections, meds, etc.)
- neurologic compression - progressive motor deficit w radiographic correlation
- need surgery urgently - instability
- deformity
what are 2 anterior approach surgical procedures
ACDF - cervical discectomy w or w/o fusion
ACD (TDR) - disc arthroplasty (artificial disc)
what are 3 posterior decompression surgical procedures
foraminotomy
laminaplasty
laminectomy
what is a laminectomy
removal of vertebral lamina to decompress SC (w or w/o fusion)
what is a laminoplasty
lamina is moved to expand space for SC
what is a foraminotomy
intervertebral foramen or canal is enlarged w goal of removing tension or compression on nerve root
- only the portions of disc that are pressing on nerve root are removed
what are indications for a discectomy & what are the 2 strongest indications
STRONG
- acute myelopathy or myeloradiculopathy (affecting gait, LE weakness)
- progressive neuro deficit
ADDITIONAL INDICATIONS
- failure of conservative treatment (refractory)
- significant motor deficit
- severe incapacitating pain (not responding to any form of treatment) - as long as corresponding imaging
what does ACDF stand for
anterior cervical discectomy and fusion w anterior cervical plate fixation
what are 4 types of materials used for an ACDF and what is the most typical
allograft bone
autograft bone
synthetic alternative
PEEK cage
most done w small ant plate w screws for stabilization
what is the purpose of a plate in an ACDF
stabilize while bone heals
how does the spine heal after an ACDF
bone fuses and becomes solid block of bone which allows for no motion
what are typical precautions after an ACDF
lifting and activity restricted for first 6wks
**no traction or manip for 3 mo
**no joint mob near replaced segments
what is the rehab focus post-op ACDF
ice to neck 10min up to 3x/day
walking program
deep neck strengthening and stability exercises
what is the most important precaution after an ACDF
**no traction or manip for 3 mo
**no joint mob near replaced segments
what are 3 common temporary sx post op ACDF
hoarseness
difficulty swallowing
dizziness
when does PT start after ACDF
weeks 3-6
what does PT in the hospital post ACDF look like
log rolling/posture
walking progression
cervical collar
how long can it take for graft to heal post ACDF
up to 1yr
rehab plan weeks 1-2 post ACDF (3)
progress walking & endurance
gentle AROM PAINFREE
no lifting >10#
rehab plan weeks 2-4 post ACDF (3)
AROM R & L (may use 2 finger to provide assistance)
aerobic exercise - walking/UBE
deep neck ms strengthening - isometrics
what is the goal of rehab weeks 4-12 post ACDF
return to PLOF
rehab plan weeks 4-12 post ACDF (3)
progress lifting </= 10-30#
progress deep neck ms strengthening (multilimb, dynamic, etc.)
UE resisted exercise
rehab plan 3-6mo post ACDF (2)
self progression on higher level activities
progress exercises
why might a pt still have arm pain after an ACDF
can happen if disc was compressing nerve root for weeks
- lots of inflammation had formed and takes time to resolve
what negative outcome is associated with spinal fusion seen in ACDF
adjacent segment dz
why might someone develop a clinically significant disc dz at levels adjacent to fused discs in ACDF (3)
altered biomechanical stresses
surgical disruption of soft tissue
natural hx of cervical disc dz
outcomes from an ACDF vs non-surgical management and what is the take away from this
surgery resulted in more rapid improvement in 1st year post op
- after 2 years no different
- no difference in long term outcomes
structured PT should be tried before surgery (if possible)
what is the significance of a Mobi C as an artificial disc device
bone sparing fixation
what is the significance of a simplify disc as an artificial disc device
allows for use of MRI imaging
what are 3 indications for cervical disc arthroplasty
- skeletally mature
- clinically symptomatic cervical radiculopathy and/or myelopathy d/t neural compression C3-C7 at 1 or 2 contiguous levels
- failed at least 6wks of nonsurgical treatment and shows signs of progressively clinical deterioration
what is a clinically symptomatic radiculopathy or myelopathy that would indicate the need for cervical disc arthroplasty
intractable radiculopathy (arm pain and/or neuro deficit) w or w/o associated neck pain
myelopathy (d/t abnormality localized to level of disc space)
what are 6 contraindications for a cervical arthroplasty
- infection in spine or surrounding areas
- osteoporosis or osteopenia
- not good bone to attach to - severe degenerative changes/facet dz
- artificial disc allows mvmt, if facets stiff/degenerative will undergo more stress and not tolerate additional movement well - cervical instability
- allergy to metals and other materials in artificial disc
- hybrid procedure for multi-level ACDF and TDA
- fusion at one level, artificial disc at another
what is the main difference in the rehab protocol b/w ACDF and a disc arthroplasty and why
no concern ab healing fusion/protecting the graft in a disc arthroplasty
- disc removed and replacement moves so don’t have to worry ab protecting fusion
why does disc arthroplasty heal faster than an ACDF
less invasion
no fusion to worry about
what are the phases post a disc arthroplasty
phase 1: protection phase
- some restrictions wks 1-3
phase 2: intermediate
phase 3: advanced strengthening
phase 4: return to activity
what are 4 pros of TDR vs ADF
better clinical outcomes
greater segmental motion
dec rate of subsequent surgeries
lower rates of adjacent segment secondary surgeries
what is one con of TDR vs ACDF
longer term follow-up needed
what is the timeline for PT post a TDR
might start PT at 2wks
unrestricted return at 4wks
what are 3 pros of ACDF vs TDR
treat wider range of pts
- not everyone is eligible for an artifical disc
fewer unknown risks
less complicated procedure
