Cervicothoracic Spine I Flashcards
Hypomobile stiff areas may not be painful, but if not addressed, can cause what?
Painful hypermobile compensations elsewhere
Where are hypermobile compensations normally found?
The path of least resistance
Ex- stiff upper thoracic region contributes to hypermobile lower cervical spine
What can we do for stiff areas for more uniform/distributed motion?
Mobilize them
Why are hyper-mobile areas usually painful?
The axis of motion is less controlled
What do we want to do with hypermobile areas?
STABILIZE THEM
What muscle groupings are we focussing on with stabilization of hyper-mobile areas?
Smaller and deeper muscles, that are almost always inhibited to better control motion
What does the orientation of the facet joints determine?
Direction and amount of motion
What is considered the upper cervical spine?
O-C2
What plane are upper cervical facets normally in?
Transverse plane
What motion does the upper cervical spine favor?
Rotation, particularly at C1,2
What plane are the lower cervical facet joints normally in?
Between frontal and transverse planes - at around 45 degrees
What motion does the lower cervical spine favor?
All motions rather equally
What makes up the lower cervical spine?
C2-C7
What plane are the upper thoracic facet joints in?
Mostly frontal plane
Ribs limit greater side bending
What motion is the greatest in the upper thoracic spine?
Greatest with rotation
Followed by side bend, flexion
What motion is the least favored in the upper thoracic spine?
extension
Where is the most rotation in the thoracic spine?
T5 and T10
Where is the least movement in the thoracic spine?
T11 and T12
What are the four variables for stabilization?
- joint integrity (i.e. cartilage)
- Passive stiffness (i.e. ligaments)
- Neural Input
- Muscle function
What is controlled motion more than?
Just strength of superficial and “mirror” muscles
What are local muscles?
-Closer to axis of motion
- often deeper
- favor stabilization over rotary forces
- postural
- aerobic over anaerobic
What type of fibers are local muscles most often composed of?
Type I fibers
What are global muscles?
- further from axis of motion
- often superficial
- favor rotary over stabilization forces
- spurt muscles
- are anaerobic over aerobic
What type of fibers are global muscles most often composed of?
Type II fibers
What are some cervical local muscles?
- longus colli and other deep neck flexors
- suboccipitals and splenius muscle
What are some thoracic local muscles?
- rotatores and multifidus
- pelvic floor and transverse abdominus (increase contraction of multifidus)
If the Multifidi is smaller, what happens in regards to injury rates?
Higher injury rates
What does pain, swelling, joint laxity, and disuse cause?
Inhibited muscles
- particularly local muscles
What is inhibition in regards to a muscle?
Decreased and delayed motor activation and coordination
What type of muscle is inhibition preferential to?
Type I muscles
What does the multifidi do when inhibited?
atrophy and declined strength
What does inhibition do to non-contractile structures?
Increases the stress put on them
When supply is lowered, what can it lead to?
More easily overworked muscles even without doing more
Think Jan 1st starting a new exercise program… doing more and maintaining an exercise routine = overuse
Why would inhibited muscles increase the stress on the non-contractile tissues?
Muscles are not controlling the mobility well
Pain, swelling and disuse cause increased and inefficient motor activity of what group of muscles?
Global muscles
i.e. UT, SCM, Scalenes, etc
-> tightness front being “overworked”
What can pain swelling joint laxity and disuse cause for cervical proprioception?
Decreases it
sense of where you are in space is disrupted
What does atrophy lead to aside from muscle loss?
Fatty infiltration
What percentage of muscle cross sectional area is fat in the local/global muscles of those over the age of 60?
50%
What happens to the fibers of muscles when there is pain, swelling, joint laxity and disuse?
Fibers transform from type I to type II
this means they won’t function as needed anymore
Does normal muscle function return when the pain is gone?
NO
Normal muscle function doesn’t return spontaneously even when the pain is gone
What percentage of muscle activation is sufficient to keep stability and is suitable to improve muscle endurance?
30%
What is pain phenotyping?
Set of observable pain characteristics of an individual resulting from body and environment interaction
What are the three types of pain phenotyping?
- Nociceptive
- Neuropathic
- Nociplastic
What is nociceptive pain?
NON- nervous tissue compromise
-MSK including spondylogenic
-viserogenic
What is neuropathic pain?
Nervous tissue compromised
-radicular
-radiculopathy
-peripheral
What is nociplastic pain?
Altered pain perception without complete evidence of actual or threatened tissue compromise
What is spondylogenic pain from?
The spine
Is spondylogenic pain common?
Yes
What can cause spondylogenic pain?
Local and/or referred spinal pain from noxious stimulation of spine structure
Is spondylogenic pain local or global?
LOCAL pain - symptoms are at the loaction of the source
What can spondylogenic pain NOT cause?
Visceral dysfunction
What can spondylogenic pain cause in regards to shared innervations?
Somatic convergence or referred pain
Sensory afferents ___________ on and __________ same innervation, so symptoms are felt away from the source
Converge, share
What are symptoms of spondylogenic pain?
- non segmental pain
- vague, deep, achy, and boring pain
- may settle into a consistent location
- rarely paresthesias
What structures refer more than others?
Proximal and deep structures have greater referral than distal and superficial structures
ex- spinal facet joints refer more than the elbow joint
What are signs of spondylogenic pain?
- neuro scan WNL
- may not reproduce entire symptom patten with motion
Thoracic spondylogenic pain presents where?
along respective vertebral levels with overlap in trunk
What is viscerogenic pain?
referred pain from an organ
What is viscerosomatic convergence?
Viscera and somatic sensory afferents converge on and share the same innervation
What kind of pain does viserogenic pain present as?
Vague,, deep, achy and boring pain
What are signs and symptoms of viscerogenic pain?
Not typically able to be mechanically reproduced
neuro scan WNL
What is an example of viscerogenic pain?
Heart can refer to left shoulder UE, neck, jaw
- all are innervated by C4-T4 spinal nerves
What is radicular pain?
Ectopic or abnormal discharge from HIGHLY INFLAMMED spinal nerve
Is radicular pain common?
NO
What are symptoms of radicular pain?
Lancing, electrical shock like pain along an extremity in an narrow 2-3” band
What are signs of radicular pain?
-Positive dural mobility tests due to the high inflammation
-Other LMN neuro test likely WNL unless severe compression
What can be helpful to help us determine the involved spinal nerve in radicular pain?
Imaging
Is conduction of the spinal nerves lost quickly or slowly?
Takes time for conduction to be lost
What is radiculopathy?
Decreased conduction of a spinal nerve due to compression and/or inflammation
What are symptoms of radiculopathy?
-segmental paresthesias
-often constant and long duration
-slow progression to smaller ill-defined area
-dermatomal overlap
- possible weakness
What are signs of radiculopathy?
Neuro scan positive for spinal nerve hypoactivity
imaging helpful for involved spinal nerve
What are symptoms of a peripheral nerve issue?
Non segmental paresthesia
- often intermittent and short duration
- fast progression to larger well-defined area of numbness
bc of minimal overlap of peripheral nerve
Possible weakness
What are signs of peripheral nerve issues?
*Dermatomes, DTRs, and myotomes WNL
*Non-segmental peripheral nerve hypoactivity
- decreased sensation along peripheral nerve
distribution
- possible weakness of muscles innervated by a
peripheral nerve
*Positive dural mobility tests
What is nociplastic pain?
altered pain perception WITHOUT complete evidence of actual or threatened tissue compromise
How does nociplastic pain happen?
*Thinning of myelin sheath
*Increased sensitivity and misinterpretation by PERIPHERAL nociceptors
*persistant excitation of A-Delta and C fibers
What does the persistent excitation of A-delta and C fibers do?
Inhibits larger myelinated A-Beta fibers pre-synaptically
Harder to override pain with motion
How does nociplastic pain happen?
*Increased sensitivity and misinterpretation by CENTRAL structures
*Loss of descending anti-nociceptive mechanisms
What is the increased sensitivity of central structures caused by with nociplastic pain?
- Increased excitability of segmental dorsal horn neurons
- Lower synaptic resistance so pain sensations occur easier
What is the loss of descending anti-nococeptive mechanism caused by?
Less endogenous opiates released
Less pain control
What is somatic convergence?
Shared areas of innervation share symptoms
**think of spondylogenic and referred pain
How do C-fibers play a role in nociplastic pain?
They transmit pain, split and travel at least 2 spinal segments superiorly and inferiorly
domino effect
With somatic convergence the brain precieves the pain as coming from _____ _____ areas with _________ symptoms
Even more
persistent
brain homunculus “smudged”
What are some functional questionnaires for nociplastic pain?
Central sensitization inventory
Neurophysiology of Pain Test
- to assess fear avoidance, catastrophizing,
understanding
Regional specific
What is the prevalence of nociplastic pain?
Growing number of conditions
What are some examples of nociplastic pain conditions?
- migraine
- neck pain
- shoulder pain
- lateral elbow pain
- low back pain
- age-related Joint Changes
- persistent fatigue syndrome
- fibromyalgia
What are signs and symptoms for possible nociplastic pain?
More than or equal to three months of pain
regional or spreading symptoms
pain that cannot be entirely explained
pain hypersensitivity or allodynia (non-painful stimuli causing pain)
What are signs and symptoms for probable nociplastic pain?
Sensitivity to sound, light, and/or odor
sleep disturbances
fatigue
cognitive problems
What are some autonomic nervous symptom indications for nociplastic pain?
Pitting edema with lymph compromise
decreased sebaceous oil gland and hair follicle activity
- skin appears scaly and fragile
- decreased skin mobility and increased sensitivity
- positive scratch test (excessive reddening)
sweaty hands/feet
Clamminess
Loss of laterality
increased erector pili muscle activity
Positive graphesthesia (cant differentiate drawn letters/#s on skin)`
What is the manual therapy for nociplastic pain?
JM - manipulation
-> stimulated descending inhibitory pain mechanisms
induces presynaptic inhibition
-> limit pain by A-Delta and C-fibers
-> overriding of pain by A-beta stimulation
Reduces dorsal horn excitability
Decreases inflammatory mediators
What are the METs for nociplastic pain?
Low to moderate intensity global aerobic and resistance activities
2-3 x a week
30-90 mins per session
at least 7 weeks duration
- endogenous analgesia
- helps pt interpret pain and motion as non-threatening
- reorganizes homunculus
What else can we do for nociplastic pain aside from manual therapy and METs?
Neuroscience education/behavioral therapy
What is the prognosis for nociplastic pain?
Varying degrees of improvement
longer recovery
likely not full resolution of symptoms
