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Ortho PT Residency Trimester 1 > Adv Management of the Cervical Spine II: intervention > Flashcards

Adv Management of the Cervical Spine II: intervention Flashcards

1
Q

what is the intervention approach for neck pain?

A

Follow CPGs to categorize pts, consider chronicity & irritability/severity
-mobility deficits
-mvmt coordination impairments
-radiating pain
-cervicogenic HA

(CPGs are guidelines- if a tx doesn’t have evidence, this doesn’t mean it’s not clinically indicated)

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2
Q

What’s the recommendation for treating Acute Neck Pain + Mobility Deficits from the JOSPT 2017 CPG for Neck Pain?

A

“C” evidence for cervical mobilization/manipulation
“B” for thoracic manipulation and exercise

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3
Q

What’s the recommendation for treating SUBacute Neck Pain + Mobility Deficits from the JOSPT 2017 CPG for Neck Pain?

A

“C” evidence for cervical mobilization/manipulation
“C” for thoracic manipulation and exercise

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4
Q

What’s the recommendation for treating CHRONIC Neck Pain + Mobility Deficits from the JOSPT 2017 CPG for Neck Pain?

A

“B” evidence for cervical mobilization/manipulation
“B” for thoracic manipulation and exercise

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5
Q

What’s the recommendation for treating CHRONIC Neck Pain + RADIATING PAIN from the JOSPT 2017 CPG for Neck Pain?

A

“B” evidence for cervical mobilization/manipulation
“B” for thoracic manipulation and exercise

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6
Q

What’s the recommendation for treating SUBACUTE Neck Pain + Headaches from the JOSPT 2017 CPG for Neck Pain?

A

“B” evidence for cervical mobilization/manipulation

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7
Q

What’s the recommendation for treating CHRONIC Neck Pain + Headaches from the JOSPT 2017 CPG for Neck Pain?

A

“B” evidence for cervical mobilization/manipulation
“B” for thoracic manipulation and exercise

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8
Q

how to treat Neck pain with Mobility deficits?

A

-mobility interventions help improve painful motions AND coordination, strength, endurance exercise to maintain mobility

-cervical mobilization and HVLA
Gr I-II for pain, GrIII-IV and HVLA for pain/ROM

-thoracic HVLA (acute, subacute, chronic): lacking evidence

-reassess ROM or pain rating w/ ROM

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9
Q

what are some manual interventions for mobility in Neck Pain with Mobility deficits?

A

PPIVMs
PA PAIVMs
SNAGs
upglide
downglide
lateral glide
CTJ HVLA
Thoracic HVLA

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10
Q

considerations before you do HVLA

A

-red flag screening and subjective exam
-SINSS
-assessment/reassessment
-Clinical Prediction Rules (CPRs)
-clinical experience

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11
Q

clinical progression to HVLA

A

start with mobilization (PAIVMs and/or PPIVMs)

consider HVLA if:
-mobilization minimally effective/ or not tolerated
-technique has plateaued
-pressure sensitivity in target area w/ mobilization
-persistent end range ROM stiffness

-may consider starting w/ HVLA depending on situation

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12
Q

what are the neurophysiological benevifts of HVLA

A

-may decrease muscle inhibition
-may decrease muscle hypertonicity
-increases serum concentration of nociception-related biomarkers (oxytocin, neurotensin, orexin)

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13
Q

Precautions for HVLA

A
  1. Psychological health
    (psych risk factors, negative coping strategies, fear-avoidance, anxiety, depression, distress)
  2. general health
    (diabetes, hx smoking, many comorbidities)
  3. Vascular
    (abnormalities, adv CAV, PVD; hx of DVT; past/current use of anticoagulants or antithrombotics)
  4. Bony things
    (scoliosis, spondylolisthesis, Scheuermann’s Disease, spina bifida, Klippel-Feil Syndrome, stable fx, Osteopenia)
  5. Inflammatory Arthritis
    (gout, RA, AS, psoriatic arthritis, diffuse idiopathic skeletal hyperotosis [DISH], Extraglandular Sjogren’s Syndrome, Lyme’s)
  6. Connective tissue disorders (Marfan’s, EDS, Osteogenesis imperfecta, Crohn’s, Scleroderma, Lupus)
  7. neuromusculoskeletal (rubbery end feel or spasm, patient guarding; neuro deficit present but stable; hypermobility; instability)
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14
Q

Absolute Contraindications for HVLA (neuromuscular)

A
  1. NeuroMSK
    -cancer/malignancy of bone or soft tissue
    -bone disease (osteoporosis, Paget’s disease, tuberculosis, osteomyelitis)
    -RA during flare, Ankylosing Spondylitis
    -Cord involvement, acute myelopathy
    -Cauda equina
    -Neuro s/sxs >1 adjacent cervical segment or >2 adjacent lumbar nerve roots
    -severe pain and inability to find comfy position
    -high irritability
    -acute radicular pain
    -increasing/unstable radicular s/sxs
    -increase in distal sxs w/ spinal mvmts or palpation or early in ROM
    -unstable or acute fx, including compression fx
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15
Q

Absolute Contraindications for HVLA (vascular)

A

vascular:
-s/sxs of vertebral artery insufficiency or dissection
-bleeding disorders, e.g. inherited hemophilia A/B, vascular type EDS
-current use of anticoagulants
-hx of multiple DVT of spontaneous nature
-incr risk of DVT

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16
Q

Other absolute contraindications for HVLA

A

-pregnancy (and caution acutely postpartum)
-hx of oral corticosteroid [use of >5mg for >4-6 months in the past 12 months]
-Pt states he/she doesn’t want intervention
-prolonged immobilization
-bone that has been exposed to high dose radiation

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17
Q

absolute contraindications for cervical HVLA

A

-previous dx of VBI or head/neck artery dissection
-facial/ intraoral anesthesia or paresthesia
-visual disturbances
-5Ds + 3Ns + 1A (or gait disturbance)
-any sx listed above aggravated by position or mvmt of the neck
-no change or worsening of sxs after multiple HVLAs

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18
Q

what’s a diagnostic CPR?

A

Diagnostic CPR enhances detection of a specific condition. it’s developed using cross-section designs to compare CPR findings against gold standard

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19
Q

what’s a prognostic CPR?

A

Prognostic CPR:
-estimates probability that a change in state of health will occur
-good for educating pts about outcome expectations
-help to prioritize ppl for intervention

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20
Q

what’s a prescriptive CPR?

A

prescriptive CPR estimates probablity of successful outcome w/ a specific intervention

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21
Q

CPR development stages– which should we use?

A

Development stages:
1) Derivation - don’t recommend for clinical practice b/c may have poor external validity, or it could reflect change
**2) Validation: testing the CPR in a narrow or broad setting- Clinicians can use validated tools with some lvl of confidence, but caution with wider application of narrowly validated CPRs
**3) Impact Analysis: tests to see if application of CPR results in chagned clinician behavior and outcomes– clinicians can confidently use tool thatt went through impact analysis

22
Q

Current Neck CPRs- (15 prognostic and 11 prescriptive)
- most are not recommended for clinical use.
-but 4 prognostic CPRs were narrowly validated (we may consider applying it in a similar population to the derivation study)
-none of the prescriptive CPRs have been adequately validated, none have undergone impact analysis

A

x

23
Q

What’s the CPR for C/S HVLA and Neck Pain? (Puentedura 2012)

A

(Puentedura 2012)
-sx duration <38 days
-positive expectation that manipulation will help
-side to side difference in cervical rotation ROM of 10 deg or greater
-pain with PA spring testing of mid C/S

3 of 4 (+LR 13.5), probability of success improved from 39% to 90%
not validated, but we still need to know these

24
Q

What’s the CPR for C/S HVLA and Neck Pain? (Tseng 2006)

A

(Tseng 2006)
-initial score on NDI <11.50
-BIL involvement pattern
-not performing sedentary work >5 hrs/day
-feeling better while moving the neck
-doesn’t feel worse while extending neck
-Dx of spondylosis without radiculopathy

4 of 6 criteria = 88% change of success
not validated, but we still need to know these

25
Q

What’s the CPR for THORACIC SPINE HVLA and Neck Pain? (Cleland 2007)

A

(Cleland 2007)
○Sxs < 30 days
○ C/S extension < 30 deg
○ No sxs distal to shoulder
○ Looking up does not aggravate sxs
○ FABQ score < 12
○ Decreased T/S kyphosis

● 4/6 (+LR 12); 93%
● 3/6 (+LR 5.5); 86%
● Not validated

Cleland 2010 study: results didn’t support validity of 2007 CPR.
-pts who got T/S manip and exercises had better outcomes than exercise alone

26
Q

What’s the CPR for THORACIC SPINE HVLA and Neck Pain? (Saavedra-Hernandez 2011)

A

(Saavedra-Hernandez 2011)
○ Pain intensity > 4.5 points
○ C/S extension < 46 deg
○ Hypomobility of T1
○ Negative ULTT
○ Female sex
● 4/5 (+LR 1.9), 75.4%
● Not validated

27
Q

Tx strategy for Neck Pain with Movement Coordination Impairments or WAD

A

establish trajectory of the pt based on chronicity and risk factors for poor prognosis

  1. mild problems w/ rapid recovery
  2. moderate problems w/ incomplete recovery
  3. severe problems w/o recovery
28
Q

how to treat acute phase (<6 wks) of Neck Pain with Movement Coordination Impairments or WAD?

A

-Positive prognosis in acute phase (<6 wks)
- wean from cervical collar
-begin ROM and postural exercises, postural awareness
-normal activities are tolerated

29
Q

how to treat subacute phase (6-12 wks) of Neck Pain with Movement Coordination Impairments or WAD?

A

-poorer prognosis in subacute phase (6-12 wks)
—manual therapy: cervical mobilization/manipulation and thoracic manipulation
—regionally based exercise to C/S and T/S for ROM and pain mgmt
——– (like low load isometrics, coordination/stabilization exercises)

30
Q

how to treat prolonged sxs (>12 wks) in Neck Pain w/ Mvmt Coord. Impairment //WAD

A

prolonged sxs >12 wks:
-progressive cervical, scapular, thoracic strengthening, endurance, and flexibility (start low-load)
-Functional training
-Cognitive Behavioral Therapy
-Screen need for vestibular rehab, oculomotor training

31
Q

specific exercise for neck pain w/ mvmt coord impairment //WAD

A

deep neck flexor training!!!

-evidence to use it. also indicated for ppl w/ difficulty doing craniocervical flexion test or deep neck flexor endurance test
(chronic neck pain, WAD, cervicogenic HA, general coordination dysfunction)

32
Q

when observing motor control during cervical flexion AROM (seated), what should you look for?

A

flexion initiated with craniocervical flexion, then lower cervical segments

33
Q

when observing motor control during cervical extension AROM (seated), what should you look for?

A

extension initiated from lower C/S then lastly craniocervical. should see head move posterior to frontal plant of the shoulders

34
Q

how would you start deep neck flexor training?

A

supine first, if able
-chin tuck: initiate with eye mvmt, facilitate craniocervical flexion
- 10sec x 10, work up to 28-30mmHg, 2x/day. or have them monitor the SCM to see if it turns on if BP cuff isn’t available

-progress to adding a head lift until able to lift an inch

-reclined sitting with head supported if unable to do in supine

35
Q

deep neck flexor training progression options:

A

isometric holds in different parts of ROM
-eccentric control into extension w/ increasing ROM
-incorporate into other activities/positions: sitting, standing, kneeling, quadruped, prone, adding arm/leg mvmt

36
Q

How do you assess deep neck extensors?

A

-Look at motor control during AROM (quadruped or standing/sitting with fwd lean, prone on elbows if enough T/S extension ROM), can also treat in these positions

-watch for poor patterns

37
Q

What are poor mvmt patterns of the deep neck extensors?

A

-dominant upper C/S extension pattern (chin poking out), head not moving posteriorly
-head moving posteriorly but with poor eccentric control during AROM

38
Q

neck extensor assessment/tx for suboccipitals

A

in quadruped- c/s extension: you stabilize the patient’s C2 to isolate mvmt to upper C/S. as pt improves you can remove stabilization
-maintain mid-lower Cervical neutral as pt performs craniocervical flexion/extension and small rotations (<40deg)

-watch for uncoordinated/not smooth mvmt or inability to keep mid-lower C/S stable

39
Q

neck extensor assessment/tx for lower cervical?

A

In prone on elbows: cervical ext. while maintaining upper C/S neutral (not leading with chin poking out) - this biases multifidus and semispinalis cervicis

-eccentric control into flexion, concentric control back to neutral while maintaining craniocervical flexion

-layer on suboccipital muscle training for isometrics of these muscles

40
Q

How to train deep neck stabilizer co-contraction?

A

co-contraction of deep neck stabilizers occurs w/ any position/exercises there the head is unsupported.

-exercise examples:
-submaximal isometrics into cervical rotation (small ROM, lead with eyes, slow ramp up from 0-X % effort level. recommend low effort level for deep stabilizers)
-AROM
-joint position error re-training in small ROM (similar benefits to CCF training)

41
Q

assessing scapulothoracic/shoulder muscles – why? and how?

A

why- UE muscles transfer load from the limbs to the axial skeleton, so muscle imbalance may put excess pressure on C/S

how- to assess scapular position:
- assess patient in diff scap positions, with diff scap/UE mvmts and assess for changes in sxs
- check scapulothoracic ROM, muscle control/strength/ length

42
Q

with regards to scapulothoracic/shoulder muscles, neck pain is associated with which?

A

-neck pain is associated with:
1. increased upper trap activity
2. decreased ability to relax upper trap particularly w/ activity above shoulder lvl
3. Decreased and delayed activation of serratus anterior

43
Q

scapulothoracic/shoulder muscle exercise - initial stages

A

initially: relative isolation of specific muscle action on scapula

-precise, specific, painfree, short of fatigue, many reps, low load
-can progress from sidelying to prone
- progress from relative isolation to co-contraction

44
Q

scapulothoracic/shoulder muscle exercise progression

A

-scap control w/ UE mvmt
- scap control w/ low load (weights, theraband)
-scap control in WBing (eg. quadruped)
-scap control related to specific function

45
Q

Tx for ACUTE Neck Pain with Radiating Pain

A

-low level laser therapy
-short term use of cervical collar
-manual therapy
-mobiltiy and stability exercise

46
Q

Tx for CHRONIC Neck Pain with Radiating Pain

A

-intermittent cervical traction w/ home unit
-manual therapy
-nerve mobilization (sliders rather than tensiioners)
-neck-specific exercise
-general exercise
-cognitive behavioral therapy

47
Q

What are some interventions for radicular pain?

A

traction, nerve glides, contralateral lateral glides (R lateral glide at C5), median nerve slider

48
Q

what does the evidence from Romeo, 2018 say about traction?

A

Romeo, 2018:
-low lvl and moderate evidence to support mechanical and manual traction for reduction in pain and disability in pts with cervical radiculopathy (CR)

-traction applied in 15 deg flexion or position of comfort
-mechanical parameters:
—– intermittent
—– 15-50 minutes
—– 5-9 kg
-one limitation: homogeneity in diagnostic criteria for CR

49
Q

What does the literature (Basson 2017; Cupta 2012; Coppieters 2003) say about neurodynamic treatment?

A

Basson, 2017: “neural mobilization is effective in the mgmt of nerve-related LBP, nerve-related neck and arm pain, and plantar heel and tarsal tunnel syndrome”)

Gupta, 2012: imprvement in pain, function and ROM w/ medial nerve glider

Coppieters, 2003: increased ROM and decreased pain w/ contralateral lateral glides

50
Q
A

Ortho PT Residency Trimester 1 (3 decks)

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