Cervical Spine TBC Flashcards
Neck Pain Impact
One-month prevalence of activity interfering neck pain is from 7.5% -14.5%. The 12-month prevalence of neck pain-limiting activities was estimated as 1.7% (limited ability to work due to neck pain) 2.4% (limited social activities due to neck pain) 11.5% (limited activities due to neck pain).
Three levels of classification
- First Level: Is the patient appropriate for physical therapy management? 2. Second Level: What is the level of acuity? (staging the patient) 3. Third Level: What treatment should be used? (classification)
Red Flags - Spinal Fractures
Major trauma, severe limitation during active range in ALL directions
Red Flags - Cervical Myelopathy
Sensory disturbance of the hands; Muscle wasting of hand intrinsic muscles; Unstead gait; Hoffman reflex (flick middle finger); hyperreflexia; bowel and bladder disturbances; multisegmental weakness, sensory changes, or both
Red Flags - neoplastic conditions
Age over 50; previous history of cancer; unexplained weight loss; constant pain w/out relief at rest; night pain
Red Flags - Upper Cervical ligamentous instability
Occipital headache and numbness; severe limitation during neck active range of motion in all directions; signs of cervical myelopathy
Red Flags - Vertebral artery insufficiency
Drop attacks, dizziness, dysphagia, dysarthria, diplopia, positive cranial nerve signs
Red Flags - Inflammatory or systemic disease
fever >100*F, BP >160/95 mmHg, resting pulse > 100 bpm, resting respiration >25 bpm, fatigue
Red Flags - Vertebrobasilar Insufficiency
The Five D
Yellow Flags
Belief that pain is harmful or disabling resulting in guarding and fear of movement; believe that all pain must be abolished before returning to work; expectation of increased pain with activity or work; lack of ability to predict capabilities; catastrophizing; belief that pain is uncontrollable; passive attitude toward rehab; use of extended rest; reduced activity level; withdrawal from daily activities; avoidance of normal activity and progressive substitution of lifestyle awy from productive activity; reports of extremely high pain intensity; excessive reliance on aids (eg braces or crutches); sleep quality reduced following onset of back/neck pain; high intake of alcohol or other substances with pain onset; smoking
Stage 1 findings
substantial functional limitations that interfere with ADLs; difficulty concentrating at work, driving, reading for a prolonged period, or sleeping; NDI scores > 20%
Stage 2 findings
Able to perform most ADLs without difficulty; unable to perform demanding or prolonged physical activity especially when attempting complex tasks; NDI <20%
Mobility Classification
Recent onset of symptoms; no radicular signs/symptoms; no hx of surgery; age manual therapy and exercise; manipulation/mobilization of thoracic or cervical spine
Centralization Classification
Radicular signs/symptoms; symptoms distal to elbow; peripheralization/centralization of symptoms with neck movements -> activities to promote centralization; mechanical or manual traction; repeated movement to centralize symptoms
Exercise and Conditioning Classification
Longer duration of symptoms (>30 days); no signs of nerve root compression; lower pain and disability scores -> neck muscle strengthening; upper extremity strengthening
Pain Control Classification
Recent traumatic onset (whiplash); high pain and disability scores; intolerance for most activities -> cervical mobilization; active range of motion; avoid cervical immobilization
Reduce headache classification
chief complaint of headaches accompanying neck pain; headache affected by neck movement; no history or signs of migraine; unilateral headache; headache reproducible w/palpation to C0-3; restricted neck ROM -> manipulation/mobilization of the cervical spine; strengthening of the cervical deep neck flexors; scapular muscle strengthening
Hoving et al NNT
3 for manual therapy, 7 for traditional therapy
Costs
Manual therapy < traditional therapy < general practitioner
Mobilization vs Manipulation
no significant difference!
Manual techniques for cervical spine
mobilization, manipulation, muscle energy techniques
Walker et al results
Manual therapy and exercise group only 22% sought follow up care, Minimal Intervention 46% sought follow up care
Walker et al Conclusion
impairment-based manual therapy and exercise provides superior short and long term outcomes for MND patients
Reference standard for success
quite a bit better, a great deal better, and a very great deal better -> statistically/clinically significant improvement
Cleland validation study results
CPR did not identify patients likely to respond to thoracic spine manipulation (TSM); superior outcome for those receiving TSM; take home: TSM + EB strengthening program improves outcomes
Puentedura thoracic vs cervical RCT results
cervical manip > thoracic manip
Puentedura CPR for patients likely to benefit from cervical manips - CPR
CPR: ≥ 3 factors out of: symptoms 10* rotation diff, pain w/PA spring testing middle cervical spine
Puentedura CPR for patients likely to benefit from cervical manips - results
NPRS significant decrease for CPR+ patients, probability of success inc from 38% to 90%
Centralization Classification - activities to centralize movements
traction, repeated retraction
Cervical radiculopathy tests
ipsalateral cervical rotation s test
Centralization Classification interventions
cervical lateral glides, thoracic spine manipulation, strengthening exercises, intermittent cervical traction
intermittent cervical traction parameters
starting at 18 lbs, increasing 1-2 lbs based on patient response; 15 minutes duration; 30/10 on/off time; cervical spine in ~25* flexion
Raney CPR for cervical traction and exercise
3 of 5 of the following had a 79.2% chance of success (vs 44% w/no predictors): +distraction, age >55, + shoulder abduction test, +ULTT A, symptom peripheralization w/mobility testing of C4-7
Ylinen active neck muscle training - Treatment
Strength: theraband resisted flexor exercise, shoulder/UE dumbbell ex, trunk/leg training, stretching, aerobic training; endurance training: supine head lifts (3x20), shoulder/UE dumbbell ex , trunk/leg training, stretching, aerobic training
Ylinen active neck muscle training - Results
Theraband best
Headache epidemiology
16% one day prevalence; 10-12% migraine annual; tension type 38% annual; significant cost due to missed work
cervicogenic headache diff dx
unilateral without side shift; occipital to frontopatietal and orbital; chronic or episodic; moderate to severe; 1 hr to weeks duration; pain is non-throbbing, non-lancinating, usually starts in neck; triggered by neck movement, postures, pressure over C0-3; associated symptoms include decreased ROM and milder migraine-like symptoms
migraine diff dx
60% unilateral with side shift; frontal, periorbital, temporal; 1-4 per month; moderate to severe;duration 4-72 hr, pain is throbbing/pulsating; multiple triggers, neck movement not usually one; associated symptoms: nausea, vomiting, visual changes, phonophobia, photophobia
tension-type headache diff dx
diffuse bilateral; diffuse location; 1-30 per month; mild to moderate severity; last days to weeks; pain is dull; triggers are multiple, not usually neck movement; associated symptoms include decreased appetite, phonophobia, photophobia
cranial cervical flexor endurance test
supine, avoid SCM activation, tuck chin without retraction; normal is 10 seconds w/out compensations
neck flexor muscle endurance test
supine, patient tucks chin and elevates head; normal >38 seconds, pain <23 seconds
Jull cervicogenic article results
manip + exercise = best outcomes;
Jull cervicogenic article treatment
manual therapy: high/low velocity to specific cervical mobility restrictions; ther ex: low load endurance (longus capitus and colli in supine, serratus and lower trap), 2x daily, postural education throughout day
Jull NNT
2.6 MT+Ther Ex; 3.4 MT only; 3.8 ther ex only
Self mobs outcomes
immediate improvement in flexion-rotation test ROM of 15 degrees, decrease in headache severity at 4 and 12 months
WAD chronicity
1/3 of patients progress to chronic WAD
WAD prognosis
adreno-sensitive environments (car crash, work) worse prognosis
Fritz TBC article
matched interventions better than therapist selected (73% vs 54% experienced detectable change) HOWEVER <50% matched
