3. Classification for Pts w/ Neck Pain Flashcards
WHY classify neck pain?
- Generalized tx’s applied to all pts w/ neck pain are NOT going to yield predictable and effective outcomes
- So…classification into subgroups may yield better results
Classification Subgroups for mechanically based interventions
Proposed intervention-based 5 Classification Groups based on hx and phys. exam: 5
- Mobility
- Centralization
- Exercise and Conditioning
- Reduce HA (cervicogenic)
- Pain Control
*NOTE: You do not need to move pts from one to the other like LBP→ just find where they go
RED FLAGS for Mechanically Based CS Interventions
KNOW THEM!!!
See chart for sx’s
- Cervical Myelopathy*
- Neoplastic Cond’s
- Upper Cervical Ligamentous Instability
- Vert AA Insuff
- Inflamm or Systemic Disease
RED FLAGS
Cervical Myelopathy
- sensory disturbs in hands
- MM wasting of hand intrinsics
- thenar em.
- unsteady gait
- Hoffman’s
- Hyperreflexia→ UMN
- B&B disturbs
- multisegmental weakness and/or sensory changes ex. LEs also
RED FLAGS
Neoplastic Conds
- >50yo
- prev hx of cx
- unexplained wt loss
- constant pain, no relief w/ bed rest
- Night Pain***
RED FLAGS
Upper Cervical Ligamentous Instability
- Occipital HA and numbness
- Severe limitation during neck and AROM in all directions
- signs of cervical myelopathy
- traumatic injury to neck not imaged
RED FLAGS
Vert AA Insuff.
- drop attacks
- dizzy/lightheadedness related to neck mvmt
- dysphagia
- dysarthria
- diplopia
- CN signs
RED FLAGS
Inflamm or Systemic Disease
- Temp >37deg C
- BP >160/95mmHg
- Resting pulse >100bpm
- Resting respiration >25bpm
- Fatigue
YELLOW FLAGS
*suggest that pt may have slower than expected response to tx OR less favorable prognosis for improvement
2
- Attitudes and Beliefs
- Behaviors
*These are clinical yellow flags indicating heightened fear-avoidance beliefs
What should you remember about pain control subgroup?
Do NOT want them here long!!!
Pain Control Subgroup
Classification, Exam findings, Intervents
-
Classification:
- Pain Control
-
Exam Findings:
- high pain/disability scores
- very recent onset of sx’s
- sx’s precipitated by trauma
- referred or radiating sx’s extending into UQ
- poor tol for exam or most interventions
Additional proposed interventions:
Pain Control Subgroup
- Cervical mobs→ low grade/gentle; may include gentle manual traction if tolerated
- Massage→ reduce fluid stasis and mm spasm
- *Cervical collar for BRIEF Pd (<1wk)→ more harm than good
see pics for more on Cervical collar
More Notes on Pain Control Subgroup
how should they be progressed?
- Pts in this subgroup should be progressed to one of the other subgroups as quickly as approp.
- 1wk max, 2wks absolute max
- Wean off passive modalities and progress pts involvement w/ self-care and ex’s over the course of 1-2wks
2 things about this subgroup
- MOST pts end up here @ some point
- Approp for MOST pts even if in other subgroups as well
Exercise and Conditioning
Exercise and Conditioning Subgroup
Classification, Exam findings, Intervents
-
Classification:
- Conditioning and Incd Ex Tolerance
-
Exam Findings:
- lower pain/disability scores
- longer duration sx’s
- no signs nerve root compression
- No peripheralization during ROM
-
Interventions:
- strength/endurance ex’s for mm’s of neck and UQ
- Aerobic conditioning
Additional Pt Profile/Exam Findings for Exercise and Conditioning Subgroup:
*not a rule, but generally….
- Sx’s present for >30d and/or pt is >60yo
- In gen, NON-radicular neck pain and no sig motion los
-
***If MVA or Whiplash:
- event was >30d ago
- if <30d ago→ initial pain and disability ratings relatively LOW***
Related to Exercise and Conditioning Subgroup
Recent focus of research on the Deep Cervical Flexor Muscles (DCFMs)
- Demo’d DEC function in chronic neck pain
- Research findings show strong support for training of DCFM to reduce chronic neck pain w/ carry over @ 12months and 3yrs
Strength and Conditioning Exercises
Deep Craniocervical flexor focused:
- practice of Craniocervical flexion test
- Ex’s use air cuff and test pos’s of CCFT for gen training and endurance→ focus on lvls (mmHg) the pt has diff w/ during the CCFT test
- *combined cervical flexion-craniocervical flexion exercise
General Conditioning Ex’s
- Scap clocks
- Theraband rows → retraction/postural correction
- Brueggers for lower traps/dec upper trap activation
- Cervical retractions:
- from prone
- from quadruped
- quadruped bird-dogs
- into ball standing w/ alt UE mvmts; w/ cervical rotation
- etc…
Mobility (Mobilization) Subgroup
Classification, Exam findings, Interventions
-
Classification:
- Mobility
-
Exam findings:
- recent onset of sx’s
- NO radicular/referred sx’s in UQ
- restricted ROM w/ side-to-side rotation and discrepancy in L/F ROM
- NO signs of nerve root compression OR periph. of sx’s in UQ w/ cervical ROM
-
Interventions:
- CS and TS mobs/manipulation***
- AROM
*REMEMBER→ limtd ROM, NO contraind’s—→ manip CS & TS but should be part of a comprehensive tx program
Mobility (Mobilization) Subgroup
Additional pt profile/exam findings
- RECENT (<30d) onset of mech. neck pain for reasons other than MVA/Whiplash
-
IF MVA/Whiplash:
- Onset <30d ago if relatively LOW initial pain and disability
- NO s/s nerve root compression
- UQ neuro screen clear; (-) spurlings, (-) ULTT, (-) distraction, (-) shoulder ABD
-
In general, <60yo
- NOTE: age >60yo is NOT a contraindication for mobilization
Evidence in favor of mob/manip for pts w/ neck pain
(mobility subgroup evidence)
Bronfort et al, Evans et al, Hoving et al, Gross et al
Cochrane review→ suggests that mob/manip IS HELPFUL for some pts w/ neck pain
Evidence in favor of mob/manip for pts w/ neck pain
(mobility subgroup evidence)
Hoving et al
Manual tx consisting of mobs (thrust and non-thrust) performed by PT was more effective in improving outcomes and more cost effective than PT tx that did not incorp a manual approach or than cont’d care by gen practitioner
Evidence in favor of mob/manip for pts w/ neck pain
(mobility subgroup evidence)
Koes et al.
manip tends to be more helpful for younger pts w/ acute neck pain
*BUT age NOT contraindication
Thoracic Spine Manipulation in pts w/ mech. neck pain who fit into “Mobility” Subgroup
- Cleland et al explored CPR for subgroup pts (mobility/manip/mobilization subgroup) for improvement after TS manipulation
-
Intervention was:
- 3 diff TS manips + CS ROM Ex’s
- 6 Factors from pts examination were found to be predictive of success→ DO NOT MEMORIZE or rigidly apply
- Sx’s <30days (strongest factor)
- No sx’s distal to shoulder
- Looking up does not aggravate sx’s
- Phys act score on FABQ <12
- Diminished upper TS kyphosis (weakest association)
- Cervical EXT ROM <30degs
So…for Mobility Subgroup
The CPR was NOT valid
What do you do now?
- As long as NO RED FLAGS or contraindications present in pt w/ mech neck pain who seems to fit into “Mobility” Subgroup→ Try TS mobs/manips!
- Important to monitor pt response so that if they are NOT improving, you can modify approach as needed!
Centralization Subgroup
Classifcation, Exam findings, Interventions
-
Classification:
- Centralization
-
Exam Findings:
- Radicular/referred sxs in the UQ
- *Scapular sx’s are BIG***
- Peripheralization and/or central. of sx’s w/ ROM
- Signs of nerve root compression present
- May have pathoanatomic dx of cervical radiculopathy
- Radicular/referred sxs in the UQ
-
Interventions:
- Mech/manual traction
- Repeated mvmts to centralize → directional pref
Signs of Nerve Root Compression:
- UQ myotomal weakness
- Dec sensation in dermatomes
- 0, 1+ DTRs
- Spurlings
- Shoulder ABD (Bacoti’s)
- Distraction
NOTE: Lumbar spine traction and directional preference
- In the L/S…traction and directional preference were 2 separate subgroups
- In the C/S→ traction and direct. pref. ex’s are bundled together into “Centralization” subgroup
Cervical Traction
Some notes…
- TRY MANUAL TRACTION FIRST!!!
- Active warmup
- Manual tech’s
- THEN workout!!!→ have them work in tissue altered state*****
Literature: Cervical Traction
see pics
- NOTE: Take-home points:
- NO conclusions can be drawn about whether traction effective for neck and back pain
- NO evidence that traction is more efficacious than other tx’s
- NO evidence that traction is ineffective tx for neck or back pain
- Evidence of Benefit: Jellad demo’d superiority of man. and mech. intermittent C/S traction PLUS conventional tx vs. conventional tx in reducing radicular and cervical pain and disability
- NOTE: LOOK UP L/S REFRESHER for:
- proposed effects
- same w C/S AND L/S
- indications
- contraindications
- proposed effects
C/S Traction:
Set Desired Parameters
- Static vs. Intermittent (RARE)
- Force
- Min: 10lbs
- Max: up to 30lbs if tolerated
- Conventional Wisdom: @ least 25lbs to actually produce separation of VBs
- Time
- typ b/w 10-20mins
- NOTE: transient soreness is normal
Rotation and LF to the side of sx’s====
More limited ROM
Directional Preference
notes…
- How to ID direct pref:
- Centralization occurs? Peripheralization?
- Reduction in sx’s and/or improvement in ROM
- NOTE: All pts that centralize have a directional pref, BUT NOT all pts that have a directional preference centralize!!!
Peripheralization Guidelines for the UE
- Upper trap pain is MORE CENTRALIZED than scapula
- Ex of pain pattern
- Sx’s in upper arm→ rep’d motions→ sx’s in scapula=> Centralization
- Sx’s in upper traps→ rep’d motions→ sx’s in scapula=> Peripheralization
Ex. Directional Preference Acts for Pts w/ Retraction/Ext Preference
SEATED
- Use a progression of force concept for C/S retraction ex’s
- Ex. Progression below assumes a pref for retraction:
- Seated (can also do supine)
- Cervical retraction (common direct pref)
- Cervical retraction w/ overpressure
- Cervical retraction + Ext
- Cervical retraction + Ext w/ oscillating rotations for overpressure
- Seated (can also do supine)
- *NOTE: C/S retraction tolerance is the GOAL
Ex. Directional Preference Acts for Pts w/ Retraction/Ext Preference
SUPINE
- Progression:
- Retraction into pillow
- Retraction off edge of plinth w/ head support
- PT gen’d end range retraction of plinth
- Traction + retraction off plinth
- Traction + retraction + Ext ***
- Traction + retraction + Ext + overpressure oscillating rotation
Ex. Directional Preference Acts for Pts w/ Retraction/Ext Preference
PRONE
Common in HA pts
- Retractions on elbows w/ chin resting on hands/fists
Cervicogenic HA Classification
Classification, Exam findings, Interventions
-
Classification:
- Reduce HA
-
Exam findings:
- U/L HA w/ onset preceded by neck pain
- HA pain triggered by neck mvmt or pos’s
- HA pain elicited by pressure on post. neck
- Positional HA (ex. sitting @ counter)
-
Interventions:
- C/S manips/mobs
- Strengthening of neck and UQ mm’s
- Postural ed.
- DCFM’s
- Lower traps (Brueggers!!!)
Jull et al (2002) compared control group of HA pts w/ HA groups receiving either c/s mobs/manips OR strengthening of deep neck and scap mm’s, OR combined manual tx + exercise
- All interventions tx groups showed sig reductions in HA compared to control
- Improves maintained @ 1-yr follow-up
- @ Short term follow up (7 and 12wks) the combined ex. + manual tx groups showed some advantage over other groups
REVIEW C/S MOB TECHNIQUES!!! Used for cervicogenic HAs as well***
Cervicogenic HA Tx
Suboccipital Release
see pics
C/S Subgroups Flow Chart
USE IT!!!!!
Neck pain assoc’d w/ Poor Postural Habits
Mckenzie’s take on it…
- referred to as “postural syndrome”; pts in this cat. typ tx’d w/ similar intervents used for the exercise and conditioning subgroup as well as postural re-ed
- Examination may be clear, as sx’s are typ due to the pt spending prolonged pds in offending posture
Postural syndromes:
Exam may ALSO reveal what?
- FHP
- protracted shoulders
- mm weakness in trunk ext’s, scap retractors and depressors, DCFMs
- tenderness and/or tightness and/or fibrosis
*NOTE: ALL C/S pts→ screen scapula!!!!!!!
Postural Syndromes:
If FHP present:
might see findings listed in:
- upper traps, lev scap, rhomboids due to chronic overstretch and overwork
- pec minor and suboccipitals due to adaptive shortening
- MAY see ROM impairs assoc’d w/ muscle tightness
WHY do pts w/ neck pain often experience sx’s related to muscular tightness/tension?
FLOW CHART!!!
Get them into a subgroup!!!
