Adv Management of the Cervical Spine II: intervention Flashcards
what is the intervention approach for neck pain?
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)
What’s the recommendation for treating Acute Neck Pain + Mobility Deficits from the JOSPT 2017 CPG for Neck Pain?
“C” evidence for cervical mobilization/manipulation
“B” for thoracic manipulation and exercise
What’s the recommendation for treating SUBacute Neck Pain + Mobility Deficits from the JOSPT 2017 CPG for Neck Pain?
“C” evidence for cervical mobilization/manipulation
“C” for thoracic manipulation and exercise
What’s the recommendation for treating CHRONIC Neck Pain + Mobility Deficits from the JOSPT 2017 CPG for Neck Pain?
“B” evidence for cervical mobilization/manipulation
“B” for thoracic manipulation and exercise
What’s the recommendation for treating CHRONIC Neck Pain + RADIATING PAIN from the JOSPT 2017 CPG for Neck Pain?
“B” evidence for cervical mobilization/manipulation
“B” for thoracic manipulation and exercise
What’s the recommendation for treating SUBACUTE Neck Pain + Headaches from the JOSPT 2017 CPG for Neck Pain?
“B” evidence for cervical mobilization/manipulation
What’s the recommendation for treating CHRONIC Neck Pain + Headaches from the JOSPT 2017 CPG for Neck Pain?
“B” evidence for cervical mobilization/manipulation
“B” for thoracic manipulation and exercise
how to treat Neck pain with Mobility deficits?
-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
what are some manual interventions for mobility in Neck Pain with Mobility deficits?
PPIVMs
PA PAIVMs
SNAGs
upglide
downglide
lateral glide
CTJ HVLA
Thoracic HVLA
considerations before you do HVLA
-red flag screening and subjective exam
-SINSS
-assessment/reassessment
-Clinical Prediction Rules (CPRs)
-clinical experience
clinical progression to HVLA
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
what are the neurophysiological benevifts of HVLA
-may decrease muscle inhibition
-may decrease muscle hypertonicity
-increases serum concentration of nociception-related biomarkers (oxytocin, neurotensin, orexin)
Precautions for HVLA
- Psychological health
(psych risk factors, negative coping strategies, fear-avoidance, anxiety, depression, distress) - general health
(diabetes, hx smoking, many comorbidities) - Vascular
(abnormalities, adv CAV, PVD; hx of DVT; past/current use of anticoagulants or antithrombotics) - Bony things
(scoliosis, spondylolisthesis, Scheuermann’s Disease, spina bifida, Klippel-Feil Syndrome, stable fx, Osteopenia) - Inflammatory Arthritis
(gout, RA, AS, psoriatic arthritis, diffuse idiopathic skeletal hyperotosis [DISH], Extraglandular Sjogren’s Syndrome, Lyme’s) - Connective tissue disorders (Marfan’s, EDS, Osteogenesis imperfecta, Crohn’s, Scleroderma, Lupus)
- neuromusculoskeletal (rubbery end feel or spasm, patient guarding; neuro deficit present but stable; hypermobility; instability)
Absolute Contraindications for HVLA (neuromuscular)
- 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
Absolute Contraindications for HVLA (vascular)
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
Other absolute contraindications for HVLA
-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
absolute contraindications for cervical HVLA
-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
what’s a diagnostic CPR?
Diagnostic CPR enhances detection of a specific condition. it’s developed using cross-section designs to compare CPR findings against gold standard
what’s a prognostic CPR?
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
what’s a prescriptive CPR?
prescriptive CPR estimates probablity of successful outcome w/ a specific intervention
CPR development stages– which should we use?
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
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
x
What’s the CPR for C/S HVLA and Neck Pain? (Puentedura 2012)
(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
What’s the CPR for C/S HVLA and Neck Pain? (Tseng 2006)
(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
What’s the CPR for THORACIC SPINE HVLA and Neck Pain? (Cleland 2007)
(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
What’s the CPR for THORACIC SPINE HVLA and Neck Pain? (Saavedra-Hernandez 2011)
(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
Tx strategy for Neck Pain with Movement Coordination Impairments or WAD
establish trajectory of the pt based on chronicity and risk factors for poor prognosis
- mild problems w/ rapid recovery
- moderate problems w/ incomplete recovery
- severe problems w/o recovery
how to treat acute phase (<6 wks) of Neck Pain with Movement Coordination Impairments or WAD?
-Positive prognosis in acute phase (<6 wks)
- wean from cervical collar
-begin ROM and postural exercises, postural awareness
-normal activities are tolerated
how to treat subacute phase (6-12 wks) of Neck Pain with Movement Coordination Impairments or WAD?
-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)
how to treat prolonged sxs (>12 wks) in Neck Pain w/ Mvmt Coord. Impairment //WAD
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
specific exercise for neck pain w/ mvmt coord impairment //WAD
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)
when observing motor control during cervical flexion AROM (seated), what should you look for?
flexion initiated with craniocervical flexion, then lower cervical segments
when observing motor control during cervical extension AROM (seated), what should you look for?
extension initiated from lower C/S then lastly craniocervical. should see head move posterior to frontal plant of the shoulders
how would you start deep neck flexor training?
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
deep neck flexor training progression options:
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
How do you assess deep neck extensors?
-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
What are poor mvmt patterns of the deep neck extensors?
-dominant upper C/S extension pattern (chin poking out), head not moving posteriorly
-head moving posteriorly but with poor eccentric control during AROM
neck extensor assessment/tx for suboccipitals
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
neck extensor assessment/tx for lower cervical?
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
How to train deep neck stabilizer co-contraction?
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)
assessing scapulothoracic/shoulder muscles – why? and how?
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
with regards to scapulothoracic/shoulder muscles, neck pain is associated with which?
-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
scapulothoracic/shoulder muscle exercise - initial stages
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
scapulothoracic/shoulder muscle exercise progression
-scap control w/ UE mvmt
- scap control w/ low load (weights, theraband)
-scap control in WBing (eg. quadruped)
-scap control related to specific function
Tx for ACUTE Neck Pain with Radiating Pain
-low level laser therapy
-short term use of cervical collar
-manual therapy
-mobiltiy and stability exercise
Tx for CHRONIC Neck Pain with Radiating Pain
-intermittent cervical traction w/ home unit
-manual therapy
-nerve mobilization (sliders rather than tensiioners)
-neck-specific exercise
-general exercise
-cognitive behavioral therapy
What are some interventions for radicular pain?
traction, nerve glides, contralateral lateral glides (R lateral glide at C5), median nerve slider
what does the evidence from Romeo, 2018 say about traction?
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
What does the literature (Basson 2017; Cupta 2012; Coppieters 2003) say about neurodynamic treatment?
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
