C-spine manual therapy Flashcards
“manipulation”
“quick stretching maneuver”
muscles relax, joints unlock
what are the risks?
606 cervical artery dissection cases reported in 20 studies meeting selection criteria
- 54% internal carotid artery dissection
- 46% vertebral A dissection
- 61% classified as spontaneous
- 30% associated w/ trauma/trivial trauma
- 9% associated w/ cervical spine manic
- temporal relationship of an event w/ the onset of symptoms does not necessarily imply causation
*stroke following c-spine
are there safer and equally effective alternative interventions?
- some (and growing) evidence for efficacy of neck manipulations
- much less evidence for many other routinely performed interventions
- cervical spine mobilization is not risk free
- traction, PROM, strengthening exercise are not risk free
vertebral artery
anterior (internal carotid) and posterior (VA) systems
- C2 and higher most vulnerable for problems
- contralateral rotation w/ extension thought to be most stressful
stretch/pinch separates inner and outer lining
- internal bleed
- thrombus –> embolus
- possible delay between stimulus and embolus
VBI tests do NOT test the internal carotid (small % of strokes)
incidence of manipulation induced stroke
true numbers difficult to obtain:
-under reported in the literature
-delay between manip and stroke clouds correlation and causation
(was neck pain from dissection in progress and that is what led pt. to have manic??
vertebral basilar (artery) insufficiency tests
- no not do the test if VBI is suspected
- sensitivity and specificity are poor
- all descriptions include sustained (10 second) end range rotation (some include distraction and/or extension)
supine
10 seconds in extension
max rotation each way- 10 seconds each
VBI signs
Dizzyness Disarthria-slurred speech Disphagia-trouble swallowing Diplopia- double vision Drop attacks nausea Numbness- around mouth/1 side of body Nystagmus- involuntary eye movement Headache Hearing disturbances- tinnitus (ringing) Ataxia
***PAIN– may be the only symptom in spontaneous cervical artery dissection
pain
may be the only symptoms in spontaneous cervical artery dissection
-quality, intensity, topography of pain was heterogenous
-there is a high frequency of headache in patients w/ vertebral artery dissection even w/out sub-arachnoid hemorrhage or any neurological deficit
“this is like pain I’ve never felt before”
minimize risk
assess patients carefully & thoroughly
HISTORY:
- BP- hypertension (systolic >180, diastolic >100)
- migraine
- smoking
- trauma
- arteriosclerosis
PHYSICAL EXAM:
** if there is a strong likelihood of VBI, provocative pre-manip tests should NOT be performed, and the pt should be referred
differentiating vasculogenic head and neck pain
slide 19
chiropractic manipulations
performed by chiropractors in the context of:
- professional theory: “Law of the nerve”
- examination & assessment
OMPT manipulations
performed by PTs in the context of:
- professional theory: aligned w/ medicine
- examination and assessment
WHO is treated w/ manipulation?
OMPT= only those who fall into relevant classification and whose signs and symptoms are consistent w/ whom there has been documented evidence based efficacy
for the c-spine:
- NOT neck pain w/ movement coordination impairments including whiplash
- NOT neck pain w/ radiating pain
WHAT do we treat with manipulation?
OMPT: spinal segment(s) that lack adequate mobility and ROM
WHEN is treatment provided?
OMPT: spectrum of manual guided motion (grades 1-5); use of mst gentle grade that achieves best results. part of comprehensive treatment that also includes:
- stretching/strengthening
- soft tissue (TrP, tender points, STM)
- motor control/muscle re-ed
- pt. ed.
OA mobs
OA distraction
Sub-occipital distraction
Self mobs:
OA
AA
C2-C7 mobs
CPA/UPA
upslope
downslope
chin vs cradle hold
chin better for small hands
cradle better for big hands but
upslope
opens joint
downslope
closes joint
less likely to cavitate
direct technique
movement into the barrier to try and free up motion
indirect technique
movement away from the barrier??
