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MSPT II > 3. Classification for Pts w/ Neck Pain > Flashcards

3. Classification for Pts w/ Neck Pain Flashcards

1
Q

WHY classify neck pain?

A
  • 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
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2
Q

Classification Subgroups for mechanically based interventions

Proposed intervention-based 5 Classification Groups based on hx and phys. exam: 5

A
  1. Mobility
  2. Centralization
  3. Exercise and Conditioning
  4. Reduce HA (cervicogenic)
  5. Pain Control

*NOTE: You do not need to move pts from one to the other like LBP→ just find where they go

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3
Q

RED FLAGS for Mechanically Based CS Interventions

A

KNOW THEM!!!

See chart for sx’s

  • Cervical Myelopathy*
  • Neoplastic Cond’s
  • Upper Cervical Ligamentous Instability
  • Vert AA Insuff
  • Inflamm or Systemic Disease
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4
Q

RED FLAGS

Cervical Myelopathy

A
  • 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
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5
Q

RED FLAGS

Neoplastic Conds

A
  • >50yo
  • prev hx of cx
  • unexplained wt loss
  • constant pain, no relief w/ bed rest
  • Night Pain***
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6
Q

RED FLAGS

Upper Cervical Ligamentous Instability

A
  • Occipital HA and numbness
  • Severe limitation during neck and AROM in all directions
  • signs of cervical myelopathy
  • traumatic injury to neck not imaged
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7
Q

RED FLAGS

Vert AA Insuff.

A
  • drop attacks
  • dizzy/lightheadedness related to neck mvmt
  • dysphagia
  • dysarthria
  • diplopia
    • CN signs
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8
Q

RED FLAGS

Inflamm or Systemic Disease

A
  • Temp >37deg C
  • BP >160/95mmHg
  • Resting pulse >100bpm
  • Resting respiration >25bpm
  • Fatigue
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9
Q

YELLOW FLAGS

*suggest that pt may have slower than expected response to tx OR less favorable prognosis for improvement

2

A
  1. Attitudes and Beliefs
  2. Behaviors

*These are clinical yellow flags indicating heightened fear-avoidance beliefs

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10
Q

What should you remember about pain control subgroup?

A

Do NOT want them here long!!!

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11
Q

Pain Control Subgroup

Classification, Exam findings, Intervents

A
  • 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
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12
Q

Additional proposed interventions:

Pain Control Subgroup

A
  • 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

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13
Q

More Notes on Pain Control Subgroup

how should they be progressed?

A
  • 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
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14
Q

2 things about this subgroup

  1. MOST pts end up here @ some point
  2. Approp for MOST pts even if in other subgroups as well
A

Exercise and Conditioning

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15
Q

Exercise and Conditioning Subgroup

Classification, Exam findings, Intervents

A
  • 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
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16
Q

Additional Pt Profile/Exam Findings for Exercise and Conditioning Subgroup:

*not a rule, but generally….

A
  • 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***
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17
Q

Related to Exercise and Conditioning Subgroup

Recent focus of research on the Deep Cervical Flexor Muscles (DCFMs)

A
  • 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
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18
Q

Strength and Conditioning Exercises

Deep Craniocervical flexor focused:

A
  • 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
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19
Q

General Conditioning Ex’s

A
  • 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…
20
Q

Mobility (Mobilization) Subgroup

Classification, Exam findings, Interventions

A
  • 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

21
Q

Mobility (Mobilization) Subgroup

Additional pt profile/exam findings

A
  • 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
22
Q

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

A

Cochrane review→ suggests that mob/manip IS HELPFUL for some pts w/ neck pain

23
Q

Evidence in favor of mob/manip for pts w/ neck pain

(mobility subgroup evidence)

Hoving et al

A

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

24
Q

Evidence in favor of mob/manip for pts w/ neck pain

(mobility subgroup evidence)

Koes et al.

A

manip tends to be more helpful for younger pts w/ acute neck pain

*BUT age NOT contraindication

25
Q

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
A
  • 6 Factors from pts examination were found to be predictive of success→ DO NOT MEMORIZE or rigidly apply
    1. Sx’s <30days (strongest factor)
    2. No sx’s distal to shoulder
    3. Looking up does not aggravate sx’s
    4. Phys act score on FABQ <12
    5. Diminished upper TS kyphosis (weakest association)
    6. Cervical EXT ROM <30degs
26
Q

So…for Mobility Subgroup

The CPR was NOT valid

What do you do now?

A
  • 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!
27
Q

Centralization Subgroup

Classifcation, Exam findings, Interventions

A
  • 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
  • Interventions:
    • Mech/manual traction
    • Repeated mvmts to centralize → directional pref
28
Q

Signs of Nerve Root Compression:

A
  • UQ myotomal weakness
  • Dec sensation in dermatomes
  • 0, 1+ DTRs
    • Spurlings
    • Shoulder ABD (Bacoti’s)
    • Distraction
29
Q

NOTE: Lumbar spine traction and directional preference

A
  • 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
30
Q

Cervical Traction

Some notes…

A
  • TRY MANUAL TRACTION FIRST!!!
  • Active warmup
  • Manual tech’s
  • THEN workout!!!→ have them work in tissue altered state*****
31
Q

Literature: Cervical Traction

A

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
32
Q

C/S Traction:

Set Desired Parameters

A
  • 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
33
Q

Rotation and LF to the side of sx’s====

A

More limited ROM

34
Q

Directional Preference

notes…

A
  • 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!!!
35
Q

Peripheralization Guidelines for the UE

A
  • 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
36
Q

Ex. Directional Preference Acts for Pts w/ Retraction/Ext Preference

SEATED

A
  • 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
  • *NOTE: C/S retraction tolerance is the GOAL
37
Q

Ex. Directional Preference Acts for Pts w/ Retraction/Ext Preference

SUPINE

A
  • 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
38
Q

Ex. Directional Preference Acts for Pts w/ Retraction/Ext Preference

PRONE

A

Common in HA pts

  • Retractions on elbows w/ chin resting on hands/fists
39
Q

Cervicogenic HA Classification

Classification, Exam findings, Interventions

A
  • 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!!!)
40
Q

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

A
  • 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***

41
Q

Cervicogenic HA Tx

Suboccipital Release

A

see pics

42
Q

C/S Subgroups Flow Chart

A

USE IT!!!!!

43
Q

Neck pain assoc’d w/ Poor Postural Habits

Mckenzie’s take on it…

A
  • 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
44
Q

Postural syndromes:

Exam may ALSO reveal what?

A
  • 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!!!!!!!

45
Q

Postural Syndromes:

If FHP present:

might see findings listed in:

A
  • 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
46
Q

WHY do pts w/ neck pain often experience sx’s related to muscular tightness/tension?

A

FLOW CHART!!!

Get them into a subgroup!!!

MSPT II (20 decks)

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