Cervicothoracic Flashcards
Red flag screening
- fatigue
- fever/chill/night sweats
- unexplained weight change
- nausea/vomiting
- dizziness/light headedness
- change in mentation
Osteomyelitis risk factors
- diabetes
- hx of intravenous drug use
- recent surgery
- recent pneumonia
- immunosuppressive disorders
- unrelenting pain
- fevers/chills
- inflammatory signs
Cancer risk factors
- age>50
- hx of cancer (GREATEST PREDICTOR)
- unexplained weight loss
- no improvement > 1 month
**If no factors present sn=100%
Meningitis sx
Risk Factors:
- hx of recent infection
- hx of skull fracture
S/S
- fever
- pain on slump testing
- headache
- GI symptoms
- confusion
- seizures
- sleepiness
- photophobia
*If fever, neck stiffness, altered mental status ALL negative -can rule out Sn 99-100%
Pancoast’s Tumor - what is it?
- malignant tumor in apex of lung
* commonly misdiagnosed as cervical discogenic pain, TOS or shoulder issue
Pancoast’s tumor - s/s/risk factors
- men > 50 w/ hx of smoking
- shoulder and scapular nagging pain extending into ulnar distribution
- hand atrophy
- pulmonary symptoms
- neck and shoulder symptoms fail to improve in several treatments and risk factors are present = refer to MD
- often pressures c8-T1 nerve roots
Cervical myelopathy s/s
- gait deviation
- (+) Hoffman’s test
- (+) inverted uspinator sign
- (+) Babinski
LR increases w/ increasing positive tests
Hoffman’s test
How to perform: Grasp the patient’s middle phalanx of 3rd digit at distal end with your 2nd and 3rd distal phalanges. Flick the patient’s distal phalanx into flexion using your thumb.
Positive test: Adduction of thumb and/or flexion of fingers
Inverted supinator sign
How to perform: Using reflex hammer, strike the brachioradialis tendon near radial styloid process at distal end of radius (C6 DTR).
Positive test: Finger flexion
Upper cervical instability s/s
- occipital HA
- severe AROM limitations
- signs of myelopathy
Upper cervical instability risk factors
- hx of trauma
- RA
- down syndrome
- Os odontoideum
Upper cervical instability clinical tests
- sharp purser (sn. 88, sp. 96) - DECREASES symptoms
- transverse ligament test (provocative)
- alar ligament test
CAD risk factors
- past hx of cervical trauma
- hx of migraine-type HA
- hyperlipidemia
- cardiac/vascular disease
- previous CVA or TIA
- diabetes
- trivial head/neck trauma
- clotting disorders
- anticoagulant therapy
- long term steroid use
- recent infection
- immediately post partum
Canadian c-spine rules
- High risk factors that mandate radiography
- Low risk factors which allow safe ROM assessment
- Able to rotate
Canadian c-spine rules - high risk factors mandating radiography
1. Age >/= 65 yo OR 2. Dangerous mechanism (fall from elevation <3ft or 5 stairs, axial load to head, MVC high speed (>100km/hr), rollover, ejection, motorized recreational vehicles, bicycle struck or collision) OR 3. Paresthesias in extremities
Canadian c-spine rules - low risk factors that allow safe assessment of ROM
1. simple rear end MVC (pushed into oncoming traffic, hit by bus/large truck, rollover, hit by high speed vehicle) OR 2. sitting position in E.D. OR 3. Ambulatory at any time OR 4. Delayed onset of neck pain OR 5. Absence of midline c-spine tenderness
Canadian c-spine - neck mobility
Must be able to actively rotate 45* (L) and (R) for NO radiograph
Canadian c-spine rules DO NOT APPLY IF…
- non trauma case
- Glasgow coma scale <15
- unstable vital signs
- age < 16 years
- acute paralysis
- known vertebral disease
- previous c-spine surgery
- pregnant
Cervical manipulation and mobilization
Clinicians should consider using thrust and non-thrust to reduce neck pain and headache.
*combining these with exercise is MORE effective than using alone (STRONG EVIDENCE)
6 predictors for immediate improvement (of pain, satisfaction, or perception of condition) following c-spine thrust (Tseng et al)
- intial NDI scores less than 11.5 (23%)
- bilateral involvement
- NOT performing sedentary work >5 hours/day
- feeling better while moving neck
- do not feel worse with neck extension
- diagnosis of spondylosis w/o radiculopathy
Presence of 4 or more increase probability from 60 to 89%
HVLAT vs. Laser for cervicogenic headaches (Nilsson et al)
HVLAT reduced analgesic use by 36%, unchanged in other groups
Spinal mob and manip for chronic neck pain and headaches (Vernon et al.)
Moderate to high quality evidence suggests clinically important improvements from spinal mob/manip at 6, 12, 104 weeks post treatment
Cochrane review of cervical manip and mob
manip and mob produced similar effects - low quality evidence to support cervical manip over mob
CPR - thoracic spine manipulation for neck pain
- symptom duration <30 days
- no symptoms distal to shoulder
- looking up does not aggravate
- FABQPA < 12
- diminished upper thoracic spine kyphosis
- cervical ext <30*
(+) LR 3 or more present = 5.5
- LOOK UP PERCENTAGES*
- validation study failed because all groups improved!
CPR - traction
- age >/= 55
- (+) shoulder abduction test
- (+) ULTTA
- (+) symptom peripheralization with central PA at lower c-spine (c4-7)
- (+) neck distraction
*study still needs validation
CPR for Cervical radic treatment
- <54 years old
- dominant arm not affected
- looking down does not worsen symptoms
- receives multimodal treatments at least 50% of visits
ALL = 90%
3= 85%
2= 62%
1=55%
Outcome tools for neck pain
NDI and Patient specific functional scale - level I evidence
Cervical mobilization and manipulation - neck pain CPG recommendation
Level I and II evidence supports use.
Clinicians should consider utilization cervical manip and mobilization procedures, thrust and non-thrust, to reduce neck pain/headache. Level A
Thoracic mobilization/manip - neck pain CPG
Thoracic spine thrust manip can be used for patients with primary c/o neck pain. Level C
Stretching - neck pain CPG
- flexibility exercises can be used for patients with neck symptoms. Level C
Coordination and strengthening - neck pain CPG
Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache - level A.
Centralization - neck pain CPG
Specific repeated movements are NOT more beneficial in reducing disability when compared to other forms of intervention. Level C
Nerve mobilization - neck pain CPG
Clinicians should consider the use of upper quarter and nerve mobilization procedures to reduce pain and disability. Level B
Traction - neck pain CPG
Clinicians should consider use of intermittent cervical traction, combined with other interventions, for reducing pain/disability. Level B
Patient Ed. - neck pain CPG
To improve recovery in pateints with WAD - clinicians should education patient that early return to normal and non-provocative activities is important and provide reassurance of good prognosis. Level A.
CPG Level of Evidence (I-V)
I - Evidence obtained from high quality RCTs, prospective or diagnostic studies
II - evidence obtained from lesser quality RCTs, prospective studies, or diagnostic studies (improper randomization, no blinding, <80% follow up)
III - case controlled studies or retrospective studies
IV - case series
V - expert opinion
CPG Grades of Recommendation (A-F)
A - strong evidence B - moderate evidence C - weak evidence D - conflicting evidence E - theoretical/foundational evidence F - expert opinion
C-spine bony anatomy
- 7 cervical vertebrae
- Upper cervical (CO-1, C1-2) and lower cervical (C3-7)
- foramen in C1-7 tranasverse process = passage of vertebral artery through foramen magnum
C1
Atlas
- lacks vertebral body and SPs
- cervical flex/ext
C2
Axis
- elongated superior projection = dens
- rotation
- C1/2 = up to 1/2 of normal ROM of cervical spine occurs here
Alar ligament
- attaches to the dens and occipital condyles of cranium
- important to keep dens in close approximation of C1
Transverse ligament
- covers the dens
- attaches horizontally to C1
- also connects with longitudinal ligament creating cruciform ligament
- important to keep dens in close approximation to C1
Lower cervical spine
- articulation of facet (zygapophyseal) joints and body of vertebrae
- (B) uncovertebral joints
- potential degenerative area
Ligamentum nuchae
- expansive ligament that extends from SP of C7 to the external occipital protruberance
- increases depth of cervical SPs allowing for muscular attachment
- limits cervical flexion
Rectus capitus posterior major
Attachments: SP of axis (c2) and lateral part of inferior neuchal line of occipital bone(C0)
Action: extension and rotation of head to same side
Rectus capitis posterior minor
Attachments: posterior tubercle of atlas (c1) and occipital bone at medial portion fo inferior nuchal line.
Action: extend head at C0-1 joint
Obliquis capitis inferior
Attachments: C2 SP to C1 TP
Action: rotate skull around odontoid process to same side
Obliquus capitis superior
Attachment: TP of C1 and occipital bone between inferior and superior nuchal lines
Action: extension and lateral flexion of head to same side
Rectus capitis anterior
Attachment: lateral mass of C1 and root of TP of C1 at base of occipital bone in front of foramen magnum
Action: flexes head at CO-1 articulation
Rectus capitis lateralis
Attachment: TP of C1 to occipital bone
Action: lateral flexion of head to same side
SCM
Attachments: anterior surface of manubrium and upper surface of medial 1/3 of clavicle to lateral surface of mastoid process and lateral 1/2 of superior nuchal line on occipital bone
Actions:
- unilateral: head towards shoulder and rotates chin to the opposite side
- bilateral: extends head moving it into a forward neck position
*can assist in respiration when the head is fixed
Longis capitis
Attachments: TP of C3-C6 and inferior surface of basilar portion of occipital bone
Action: flex and assist in rotation of cervical vertebrae and head to same side
Longus colli
Attachment: bodies and TPs of T3-C3.
Divided into inferior oblique, vertical intermediate, superior oblique.
Action: flex and assist in rotating the cervical vertebrae and head
Anterior scalene
Attachment: TP of C3-C6 and ridge on surface of 1st rib.
Action:
- neck fixed - action is to elevate 1st rib
- rib fixed - laterall flex neck to same side and rotate to opposite side.
Middle scalene
Attachment: TPs of C2-C7 and upper surface of 1st rib.
Action = same as anterior scalene
Posterior scalene
Attachment: TP of C4-C6 and 2nd rib.
- neck fixed - elevate 2nd rib
- rib fixed - lateral flexion to same side
Splenius capitis
Attachment: ligamentum nuchae, SPs of C7-T3, lateral superior nuchal line and mastoid process.
Actions:
(B) w/ splenius capitis = extending cervical spine
Unilateral -laterally flex and rotate head to same side
Splenius Cervicis
Attachments: SPs of T3-6, TPs of C1-3.
Actions:
(B) w/ splenius capitis = extending cervical spine
Unilateral -laterally flex and rotate head to same side
Semispinalis capitus and cervicus
Deep to splenius capitus and cervicus.
Act with splenius muscles to extend the head.
Occipital neuralgia
-entrapment of greater occipital nerve in the semispinalis muscles.
Upper cervical spine sidebend/rotation
- sidebend and rotate opposite directions when spine is neutral (neither flexed nore extended)
- sidebend and rotation to same side when spine is in non-neutral
Lower cervical spine sidebend/rotation
*rotate and sidebend to same side
Head and neck medical screening questionnaire
- self report measure to determine if the patient has a potentially serious medical condition that mimics common MSK disorder
- any response marked “yes” would require further questioning
- questions related to stroke, VBI, meningitis, primary brain tumor, mild traumatic brain injury
NDI -MDC
5 points (10 percentage points)
OR
9.5 points (19.6 percentage points)
NDI - MCID
*5 points (10 percentage points)
OR
*19 percentage points
Neck pain with mobility deficit - common clinical findings
- <50 years of age
- acute neck pain (duration <12 weeks)
- symptoms isolated to neck
- restricted cervical ROM
Sharp purser Sn/Sp
Sp - 0.96
Sn - 0.69
Cervical thrust manipulation and safety
- recent evidence suggests no excess risk of VBI stroke associated with cervical HVLA vs. primary medical care
- premanipulative holds may be unable to ID individuals at risk
VBI symptoms
- vertigo
- tinnitus
- dizziness
- visual-perceptual disturbances
- fainting
Pec minor length assessment
*patient lying supine - negative test = patient’s shoulders align symmetrically, positive test = shoulder of shortened pec minor would lie more anterior
Pec major length assessment
- patient is supine with knees flexed
- for upper fibers - arm is horizontally abducted until stretch is felt
- for lower fibers, pec major muscle stabilized proximally and arm is flexed to 135* horizontal abduction
Anterior and middle scalene muscle length assessment
- occiput is supported by PT’s left hand
- examiner stabilizes patient’s superior medial clavicle and first rib with (R) hand
- therapist extends lower c-spine while maintaining neutral position of upper c-spine and then c-spine is taken into (L) sidebending and (R) rotation
Levator scap and posterior scalene muscle length assessment
- grasp (R) superior proximal scapula with (R) hand
- depress scapula
- cradle occiput with (L) hand
- flex and SB c-spine to the (L) with (L) rotation
Predictive factors of patient’s with neck pain who will respond favorably to c-spine HVLA
- symptom duration less than 38 days
- (+) expectation that manip will help
- side to side difference in cervical rotation ROM >/= 10*
- pain with PA spring testing of middle cervical spine
- combination of these 4 attributes considered to be most accurate predictor to ID these patients
- if patient exhibited at least 3 of 4, (+)LR was 13.5
- 2 or more of 4 68%
- 1 of 4, (+) LR 1.2
Neck pain with headache classification - clinical findings
- unilateral headache associated with neck/suboccipital area
- symptoms aggravated by neck movements or positions
- headache produced or aggravated with provocation of ipsilateral posterior myofascia and joints
- restricted cervical rom
- restricted cervical segmental mobility
- abnormal or substandard performance on the CCFT
Cervical rotation less than 45* =
C1-2 is likely the problem
Assessing C1/2 motion
- patient supine
- PT maximally flexes head/neck
- while maintaining flexion, PT rotates the patient’s head neck in each direction
- normal ROM = 45* each way
- less than 45* = limitation at C1-2
- test = positive if there is a 10* reduction visually estimated on either side
C0-1 motion assessment
ask patient to nod head while maintaining neutral spine
*have patient rotate head in one direction and then nod
Cranial cervical flexion test
- place biofeedback unit inflated to 20mmHg to fill the lordotic curve
- instruct patient to keep head stationary
- patient performs cranial cervical flexion in graded manner in 5 increments (22, 24, 26, 28, 30 mmHg) - goal is to hold each position for 10 seconds with 10 seconds rest between each stage
Abnormal response to CCFT
- unable to generate an increase in pressur eof at least 6mmHg
- unable to hold generated pressure for 10 seconds
- uses superficial neck muscles to accomplish cervical spine flexoin
- uses sudden movement of chin or pushing neck forcefully against device
Neck flexor muscle endurance test
- patient instructed to maximally retract chin and maintain position isometrically as he lifts head and neck 1 inch off plinth
- examiner places hand under patient’s head and focuses attention to skin folds created
- losing skin fold or touching therapist hand for greater than 1 second terminates test
- average time for subjects without neck pain was 38 seconds
Neck pain with movement coordination impairments - clinical findgins
- long standing neck pain (>12 weeks)
- abnormal performance of CCFT
- abnormal performance of deep neck flexor endurance test
- coordination, strength, endurance deficits of neck and upper quarter muscles
- flexibility deficits
- ergonomic ineffeciencies
Neck pain with radiating pain - clinical findings
- upper extremity symptoms - usually radicular or referred pain, that are aggravated by spurling and upper limb tension tests and reduced with distraction
- decreased cervical rotation (<60*) toward involved side
- s/s of nerve root compression
- success with reducing UE symptoms with initial exam and intervention procedures
C5 - dermatome and myotome
- deltoid (shoulder abd)
- lateral forearm
- biceps DTR
C6 -dermatome and myotome
- biceps
- ECRL/B
- distal thumb
- brachioradialis DTR
C7 -dermatome and myotome
- triceps
- FCR
- distal middle finger
- triceps DTR
C8 -dermatome and myotome
- abductor pollicis brevis
- distal 5th digit
- no DTR
T1 - dermatome and myotome`
- first dorsal interossei
- medial forearm
- no DTR
ULTTA
- scapular depression
- shoulder abduction to 90-110
- forearm supination, wrist and finger extension
- shoulder ER
- elbow ext
- C/L or I/L cervical SB
(+) ULTTA
- reproduction of all or part of patient’s s/s
- side to side difference greater than 10*
- determine the location on the symptomatic side
Spurling
clinical places a compression force of approx. 7kg through top of head in effort to further narrow intervertetebral foramen
*Sn 50%, sp. 90%
Distraction
Sn. 44%
Sp. 90%
Interventions for neck pain with mobility deficits
- cervical mob/manip
- thoracic mob/manip
- stretching
- coordination/strength/endurance ex.
Interventions for neck pain with headaches
- cervical mob/manip
- stretching
- coordination/strengthening/endurance
Interventions for neck pain with movement coordination impairments
- coordination/strengthening/endurance ex
- patient ed
- stretching ex.
Interventions for neck pain with radiating pain
- upper quarter and nerve mobs
- traction
- thoracic mob/manip
Cardio s/s
- angina
- SOB
- syncope/drop attacks
- symptom increase w/ physical activity, but without mechanical correlation
- abnormal fatigue
- decreased exercise tolerance
- pain in jaw, neck, shoulder, arm, back
- pulse irregularities
- palpitations
- peripheral edema
- nausea
- heartburn that doesn’t improve with antacids
MI s/s
- angina > 30 mins not relieved by rest, antacids, nitroglycerin
- vague chest, shoulder, mid back, arm pain
- SOB
- cold sweat
- nausea
- syncope
- rapid or irregular pulse
- high BP
Risk factors for aoritc dissection
- long standing HTN
- hx of smoking
- male
- advanced age
- prior cardiac surgery
- known aortic aneurysm
- cardiac catheterization
- connective tissue disorders
- vascular inflammation
- deceleration injury
- cocaine
- peripartum
Comorbid conditions associated w/ aortic dissection
- HTN
- smoking
- CAD
- thoracic or AAA
- peripheral artery disease
- prior stroke
- chronic renal insufficiency
Acute aortic syndrome s/s
- chest pain - abrupt, severe, tearing, radiating
- anterior pain or radiation to neck (ascending aorta)
- radiation to back or abdomen (descending aorta)
- syncope or CVA
- HTN (SBP>150mmHg)
- shock
- diastolic murmur
- pressure differential in UEs
- pulse deficits
- end organ ischemia
Pulmonary s/s
- dyspnea
- cough
- nail clubbing
- cyanosis
- discolored sputum
- wheezing
- fevers/chills/malaise
- pain on coughing, deep breathing, laughing, sneezing
- increased pain with lying supine
- decreased pain with autosplinting (lying on affected side)
PE Risk factors
- hx of PE or DVT
- immobility
- hx of abdominal or pelvic sx
- TKA, THA, leg fx
- late stage pregnancy
- lower limb fx
- pelvic or abdominal malignancy
PE S/S
- dyspnea or tachypnea
- pleuritic chest pain with deep breath or cough
- apprehension/anxiety
- tachycardia or palpitations
-absense of dyspnea and chest pain - can mrore confidently rule out
PE Well’s criteria
- Clinical s/s of DVT (minimum of leg swelling and pain with palpation of deep veins) +3
- An alternative dx less likely than PE +3
- HR greater than 100bpm +1.5
- Immobilization or surgery in previous 4 weeks +1.5
- Previous DVT/PE +1.5
- Hemoptysis +1
- Malignancy (on treatment, treated in last 6 months, or palliative) +1
<2 = 3.6%
2-6=20.5%
>6 = 66.7%
Pneumothorax - definition
- air in thoracic cage leading to lung collapse
- can be spontaneous
- may follow extreme bouts of coughing or physical exertion
- may follow penetrating wound or severe direct blow
Pneumothorax - S/S
- ipsilateral chest pain with deep breath or cough
- dyspnea
- cynosis
- significant fatigue
- tachycardia
- decreased ipsilateral chest expansion
- hyperresonance on percussion
- reduced breath sounds
- neck vein distension
- hypotension
Pleurisy
- irritation of pleural membranes
- sharp pain worsened by deep inspiration, coughing
- possibly worsened with rib and thoracic mobility assessment
- hx of viral infections, ra, or tumors
- “pleural rub” sound on auscultation
Pneumona
- bacterial or viral infection of lungs
- chest pain accompanied by other s/s of systemic infection
- coughing with various coloration of sputum
Pancoast’s tumor typical progression
- nagging pain in shoulder/scapula
- pain extends into ulnar distribution
- intrinsic hand mms atrophy
- subclavian vein occlusion causes ipsilateral UE venous distension
Cervical myelopathy s/s
- may affect LEs 1st
- lower limb weakness, stiffness, heaviness
- ataxic gait
- early fatigue
- headache and neck pain
- dysphagie or dysarthria
- numbness on one or both sides of body
- bowel/bladder disturbance
- UMN signs early on (hoffman, babinski, clonus)
- later progression to combo of UE/LE involvement, mixed UMN/LMN presentations, atrophy/weakness/hypotnoia/absent DTRs
Cervical Myelopathy risk factors
- age >45 - sensitive
- Hoffman’s
- Babinski - specific
- Gait deviation - specific
- Hyperreflexia - biceps - specific
- Inverted supinator sign - specific
- Hyperreflexia quad - specific
- Hyperreflexia -achilles - specific
CPR for Cervical myelopathy
- gait deviation
- (+) hoffman’s
- inverted supinator sign
- (+) babinski
- age >45
2 of 5 - (+) LR 3.3
3 of 5 - 30.9
4 of 5 - infinity
Canadian c-spine rules - sensitive or specific??
sensitivity - 99%!!
SNOUT!
Compression fractures
Risk factors - osteoporosis
- often begins with benign activity such as bending to tie shoes, coughing, sneezing
- pain and spasm over fx site
- increased pain with trunk flexion
Compression fracture CPR
- age >52
- no leg pain
- BMI < 22
- does not exercise regularly
- Female
2/5 - + LR 1.4
3/5 - 2.5
4/5 - 9.6
Transverse ligament test
-hold 10-20 seconds
(+) test = soft end feel, mms spasm, dizziness, nausea, facial or limb paresthesia, nystagmus, lump in throat
Contraindications to manual therapy
- multi-level nerve root pathology
- worsening neurological function
- unremitting, severe, non-mechanical pain
- unremitting night pain
- recent trauma
- UMN lesions
- SC damage
Risk factors for CAD
- past hx of cervical trauma
- hx of migraine-type HA
- hyperlipidemia
- cardiac or vascular disease
- previous CVA or TIA
- diabetes
- trivial head or neck trauma
- clotting disorders
- long term steroid use
- hx of smoking
- recent infection
- immediately post-partum
Predictors of chronic neck pain
- age>40
- concurrent LBP
- long-term neck pain symptoms
- cycling as regular activity
- decreased hand strength
- high fear avoidance beliefs
- poor quality of life
- less vitality
Cervical radic - prognosis
-long term outcomes show significant improvements in symptom intensity for 70% of patients at 2 yr follow up and 90% of patient sat 5 year follow up WITHOUT SURGERY
WAD - prognosis
-1/2 of patients with WAD develop persistent problems lasting up to 17 yrs later with symptoms most commonly reported of neck pain, radiating pain, HA
Neck Treatment Based Classificaiont
- Mobility
- Centralization
- Conditioning and exercise tolerance
- Pain control
- Headache
TBC and matched interventions
-patient’s who received matched interventions were associated with improved NDI and pain compared to non-matched interventions
TBC: Mobility
- less cerviacl ROM and symptoms isolated to neck
- will benefit from mobilization/manip
ID:
- younger (<50)
- more recent onset of symptoms (<12 weeks)
- primary impairment of decreased ROM
- symptoms localized to neck with no peripheralization
- segmental hypomobility
TBC: Centralization
-patients w/ radiating/radicular symptoms that can cause pain, N/T and weakness in the UE
ID:
- radicular/referred symptoms to upper quarter
- peripheralization or centralization with range of motion ot neck
Treatment:
- manual or mechanical traction
- repeated movements
- manual therapy
- strengthening
Cervical Radic TIC
- <60* ipsilateral cervical rotation
- ULTTA
- cervical distraction
- spurlings
3/4 = 6.1 4/4 = 30.3
TBC: strength and conditioning
-strengthening of key upper body musculature to target movement coordination impairments in those with chronic neck pain
ID
-older population with long standing, low intensity neck pain and disability - no s/s of nerve compression
Treatment:
- strength and endurance of deep neck flexor and extensor muscles
- training of postural muscles
TBC: Cervicogenic headaches
-headaches arising from MSK disorders of c-spine
ID:
- unilateral dominant headaches with neck pain
- aggravated by neck postures or movements
- TTP at upper 3 cervial joints
- decreased cervical ROM
- decreased joint mobility of c/s
- poor motor control w/ DNF testing
Treatment:
- manual and manip therapy
- exercise program
TBC: Pain control
-pain, disabilty and chronicity reduction in those people with acute, traumatic neck pain from WAD
ID:
- very high levels of pain and disability from recent traumatic incident
- no s/s of nerve root compression
treatment:
- neck AROM
- gentle graded mobilization of t/s and c/s
- education
vertebral artery
- arises from first branch of subclavian
- C5-C6 to C2 inside transverse foramina
- C2 = tortuous course**
- pierces dura at forament magnum and joints proximal basilar trunk**
** most common site of VAD
VAD #s
1 to 1.5 per 100,000
2% of ischemic stroke general population
20% of ischemic stroke in patient’s under 40
Best ways to gain info about VAD
TAKE BP!
- cranial nerve exam
- eye exam
- clear all red flags
- thorough PMH
- thorough cervical exam
- thoracic and cervicothoracic manip
- cervical mob
THEN cervical manip
Cervical myelopathy definition
-progressive, degenerative condition secondary to degeneration and structural changes in discks, infolding/thickening of ligamentous tissues into spinal canal and loss of flexibility of the capsule
What level is most frequently involved in cervical myelopathy?
C5-6
then c6-7, C4-5, C3-4
Lhermitter’s sign
-patient in sitting or supine, flex neck with emphasis on lower cervical flexion - (+) electric type sensation in the midline and occasionally into extremities
Inverted supinator sign
- patient in sitting, examiner places patient’s forearm in slight pronation on his or her foreaarm
- a series of quick strikes near the styloid process of radius at attachment of brachioradialis tendon
(+) = finger flexion and elbow extension
Best imaging for cervical myelopathy
MRI is most effective
ULTTA sensitive or specific for cervical radic?
SENSITIVE!
SNOUT!
Spurling - sensitive or specific for cervical radic?
SPECIFIC!
SPIN!
Distraction - sensitive or specific for cervical radic?
SPECIFIC!
SPIN!
Mechanical theories of WAD
early theory = rapid cervical hyperextension and large sagittal plane angular movements
high speed as well a slow speed impact studies have demonstrated potential injury
potential tissues affected are intervertebral discs, facet joints, capsules, ligaments, nerves, muscles
WAD classification
look up - quebec task force
Most commonly involved joint for cervicogenic headaches
C1-2
C/S cervical indications
- spondylitic or discogenic radicular symptoms
- myelopathy
- instability
- trauma
- tumor
- mri evidence of multiple level (3 or more) stenosis
- failed course of conservative management (minimum of 6 weeks)
Contraindications to c/s surgery
- neck pain as part of generalized pain syndrome
- serious psychological distress or impairment
- metabolic disease
Cervical spine rehab protocol
-review from week 8 of cervical spine course
