E2-Joint Mobs/Manips, Neck P! - WAD Flashcards
What is a direct and parallel joint mobilization
Parallel to joint surface- indirection of glides
At or toward point of limitation with more chronic and painless limitations
What is an indirect mobilization
Away from point of limitation in a parallel direction or possibly a perpendicular direction (aka distraction) from the joint surface
What is an indication for an indirect mobilization
Acute/painful limitation like an intra articular inclusion like a loose body
Fixated hypermobility/instability- small drawer big hole
What is the tissue integrity/Rx for P! Constant or with all accessory motions
Acute and POLICED
What is the tissue integrity/Rx for some painless accessory motion/before point of limitation
Acute/ Grade1/2 JM in neutral
What is the tissue integrity/Rx with pain at same time as point of limitation
Subacute/ Grade 2/3 JM moving out of neutral
What is the tissue integrity/Rx with pain after point of limitation
Subacute to chronic/ Grade 3/4 JM
What is the tissue integrity/Rx with painless to point of limitation
Chronic/ Grade 3/4 holds and grade 5 JM
What are the outcomes for JM
Pain levels
Reassess glide
Measure ROM
Functional tests
How many sessions should JM be performed
2-4 sessions of MT if pt pain adaptive
Window of opportunity for exercises
Contraindication or Precaution and what’s the rationale:
Constant, severe, pain, includes headache, not influenced by motion
Contraindication
Not appropriate for PT
Contraindication or Precaution and what’s the rationale:
Severe inflammation and bleeding condition
Contraindication
More bleeding
Contraindication or Precaution and what’s the rationale:
Osteopenia or menopausal women
Precaution
Damage tissue
Contraindication or Precaution and what’s the rationale:
Advanced diabetes
Contraindication
Damage tissue due to lack of sensation and compromise
Contraindication or Precaution and what’s the rationale:
Cancer hx
Precaution
Damage tissue if metastasis there
Contraindication or Precaution and what’s the rationale:
Joint hypermobility
Precaution
Increased hypermobility of fixated joint that is hypermobile to begin with
Contraindication or Precaution and what’s the rationale:
Capsular fibrosis or bony fusion that prevent any distraction
Contraindication
Damage tissue
Contraindication or Precaution and what’s the rationale:
Recent fracture, dislocation, rupture
Contraindication
Damage tissue
Contraindication or Precaution and what’s the rationale:
Local or systemic infection or tumor
Contraindication
Spread or damage tissue
Contraindication or Precaution and what’s the rationale:
Corticosteroid or anticoagulant therapy off for > 3 months
Contraindication
Damage weakened tissue
What are the adverse events of Grade 5 JM
Often mild/transient soreness like exercise
Less than medications
What are the serious events of Grade 5 JM
Fractures
Neurological/vascular compromise
Disc herniation
What should we do before manipulation
- Compression test of each spinal segment
- Slump test
- Compress hand along chest for recoil
If RT is limited even with FLX to the same side, what is indicated, why, and Rx
Ipsilateral OA jt
Occiput is put posterior and then more posterior
Glide C1 anterior and upward while stabilizing Occiput
If RT is limited even in EXT to the same side, what is indicated, why, and RX
Contralateral OA jt
Occiput is put anterior of the opposite side and then more anterior
Scoop the bowl of contralateral side
If RT is limited even in FLX and EXT, what is indicated, why, and RX
AA jt
RT is no worse
Ipsilateral- Stand opposite of affected side, SB ipsilateral side, stabilize Occiput/C1 and push C2 up the slide
Contralateral- stand opposite of affected side, SB contralateral side to stabilize Occiput, then glide C1 inferiorly and anteriorly with C2 stabilized
If SB is limited and worse in FLX, what is indicated, why, and Rx
Cervical contralateral Z jt.
SAL is put anterior and then more anterior
JM Z jt superiorly
If SB is limited and worse in EXT, what is indicated, why, and Rx
Cervical ipsilateral Z jt
IMP is put posteriorly and then more posterior
JM of Z jt more inferiorly
If SB is limited and remains restricted in FLX and EXT, what is indicated, why, Rx
Indicates U jt
Both FLX and EXT are restricted meaning not Z jt
Posterior and anterior JM on affected side U jt
If pt demonstrates during their scan neck RT but at the end SBs, what is restricted and what test is indicated
Upper thoracic region
Manubrial Test
What is general Rx for hypomobility
Mobilize area for motion
If the upper thoracic is hypomobile, what can it lead to
Hypermobile lower cervical region
Why address adjacent jts
The hypermobile region can make other jts hypermobile to compensate for the absence of movement
Why is hypermobility painful
The axis of motion is less controlled
What is the general Rx for hypermobile jts
Stabilize the jts by working the smaller deeper muscles closer to the joint
What facet jts favor all motions in the frontal and transverse planes and why
C2-7
The 45 degree angle allows the jts to move equally
What do the facet jts in the upper thoracic favor and why
Mostly frontal plane- SB
the facets are more vertical allowing for easy SB but the ribs limit that motion
What are the variables for stabilization
Jt integrity
Passive stiffness
Neural input
Muscle function
What is controlled mobility
More of the deeper smaller muscles controlling the mobility of the jt
Once a passive, non contractile tissue has healed, how do we make the jt more stable
By improving muscle function and creating more control of the smaller/deeper muscles
What are the characteristics of local muscles
Closer to axis
Often deeper
Stabilization
Tonic, postural
Aerobic
What are the characteristics for global muscles
Farther from axis
Superficial
Rotatory
Spurt muscles
Anaerobic
What muscles have a higher rate of injury
Rotators and multifidus
What muscles increase contraction of multifidus
Pelvic floor and transverse abdominus
What does pain, swelling, jt. Laxity, and disuse cause for local muscles
Decreased and delayed motor activation
Inhibition of type 1
Load supply is lowered leading to easily overworked muscles
Muscle atrophy
Increase stress on non contractile tissue
Why does pain, swelling, inflammation, and disuse cause increase stress on non contractile tissues
the force of the global muscles can end up damaging structures around the jt. because stabilization isn’t there to manage the force. therefore putting stress on noncontractile tissues
what does pain, laxity, inflammation, swelling, and disuse do to global muscles
increased and insufficient motor activity- overcompensate
decrease cervical proprioception
atrophy/fatty infiltration
fiber transformation
why is fiber transformation important when a jt has pain, swelling, laxity or disuse
the muscles loses their purpose
endurance is lost therefore integrity
what percentage of muscle activation is needed for sufficient stability and to improve endurance
30%
the patient doesnt need to go to the gym, they just need to do 30% of their muscle contraction to improve muscle function
what is nociceptive pain
non nervous tissue compromise
spondylogenic
viscerogenic
what is neuropathic pain
nervous tissue compromise
radicular
radiculopathy
peripheral
what is nociplastic pain
altered pain perception without complete evidence of actual or threatened tissue compromise
what is the source of spondylogenic pain
local and or referred spinal pain
what are the S&S of spondylogenic pain
non segmental pain
vague, deep, achy, boring pain
referred pain- not specific
neuro scans normal
can’t reproduce pattern with motion
what is referred pain
somatic convergence
sensory afferents converge on and share same innervation
what is viscerogenic pain
referred pain from organ
viscerosomatic convergence
what is viscerogenic pain S&S
cannot produce mechanically
neuro scan normal
what is radicular pain
ectopic or abnormal discharge from highly inflammed spinal nerve
what are the S&S of radicular pain
electrical shock pain
derm/myotomes, DTRs=normal
dural mobility= ++++
imaging helpful
what is radiculopathy pain
more persistent blocked conduction of spinal n due to compression and inflammation
what are the S&S of radiculopathy pain
segmental paresthesia- constant/long duration, slow progression
possible weakness
neuro scan ++++
imaging helpful
what is peripheral pain
decreased conduction of n branch
what are the S&S of peripheral pain
non segmental paresthesia- short/intermittent, fast progression of numbness
possible weakness
derm/myotomes, DTRs,= normal
dural momility= ++++
Name the pain:
referred pain
sensory, DTR, dural= normal
can’t reproduce pain with motion
what is the source/description
viscerogenic
referred pain from organ
name the pain:
Sensory, DTR= normal
can’t reproduce pain with motion
dural mobility= ++++
quick pain
what is the source/description
radicular
highly inflammed spinal n
name the pain:
Sensory, DTR, dural= ++++
possible weakness
slow progression
what is the source/description
radiculopathy
spinal n, blocked conduction
name the pain:
Sensory, DTR, dural= normal
can’t reproduce entire pain with motion
what is the source/ description
spondylogenic
local/referred spinal pain
name the pain:
Sensory, DTR= normal
dural= +++
possible weakness
short, intermittent pain
what is the source/description
peripheral
peripheral n, decreased conduction in extremity
During a Manubrial test, Pt demonstrates:
L RT with R SB
R RT with R SB
FLX minimal to no movement
EXT with R SB
What is indicated and what do we do next
Unilateral restriction- L Z jt unable to extend
Seated or side lying assess each segment
During a Manubrial test, Pt demonstrates:
L RT with R SB
R RT with R SB
FLX with R SB
EXT minimal to no movement
What is indicated and what do we do next
Unilateral restriction- R Z jt. Unable to flex
Sitting or side lying check each segment
During a Manubrial test, Pt demonstrates:
L RT minimal to no movement
R RT minimal to no movement
FLX minimal to no movement
EXT minimal to no movement
What is indicated and what do we do next
Bilateral Z restriction
Sitting or side lying checking each segment
What is a normal Manubrial test
Which ever way the neck rotates the ribs SB that way like a seesaw, in FLX or EXT there shouldn’t be much movement
What is the summary of the prevalence of neck pain
70% will experience neck pain
2nd to people with LBP in workers comp
More in women
More in older
What are the strongest RF for neck pain
Female
Hx of neck pain
What are other factors of neck pain
Over 40 years of age
Coexisting LBP
cycling
Comorbidities
Etc
What is the etiology of neck pain
Unidentified
What is neck pain normally classified as
Mechanical neck disorder
Nerve root compromise
What is functional ROM for the neck
40-50 extension
60-70 rotation while driving
What are S&S of neck pain
Varied in cervical spine and UE
Impaired scapular mechanics- muscle attachments to scapula and neck
What findings can be found in MRIs even though Pt is asymptomatic
Bulging and herniated disc
Annular tears
Cord compression
What are the structures involved with neck pain
variety and often unknown tissues
most do not have a known tissue producing symptoms
how are clinical tests related to neck pain
poor screening tools and/or lack strong diagnostic accuracy measures
what are the muscular benefits for JM in the neck
increase deep muscle recruitment
reduced superficial muscle recruitment
what are predictors of success for cervical manipulation per CPR
neck disability index <11.5
bilateral involvement
sedentary work <5 hours per day
feels better with movement
extension does not increase symptoms
OA without radiculopathy
symptoms <38 days
+ expectation with manipulation
less than or equal to 10 difference rotation
pain with PA springs
how does CPR work for cervical or thoracic manipulation
4 or more predicators of success= good outcome with JM
what are the predictors for success for thoracic manipulation
symptoms < 30 days
no symptoms to distal shoulder
extension does not increase symptoms
diminished T3-5 kyphosis
cervical extension <30 degrees
what regions should be included in MET for best outcomes with neck pain and what exercises should be done
cervical, thoracic, scapula, and shoulder
stabilization, strength and endurance parameters
what is the MET for nociplastic pain in the neck
motor control and strengthening exercises for stabilization
30-60 minute sessions
2-3x/wk
7-12 wks
what is the degree of research evidence for local and global muscles training related to neck pain
strong
what is the MET for local and global muscle training in relation to neck pain
low load endurance for 6 wks (once acute phase is over)
isotonic/metric forward nodding
isometric cervical rotation
isotonic/metric scapular exercises
how can you progress you forward head nodding for local m training
no gravity- low
gravity- high
forward nod with balance and external loads
functional exercise while maintaining forward nod
what are other strong evidence based MET exercises for neck pain
proprioceptive training - eye fixation w/ or w/out head movement, sitting tall, head relocation with eyes open then closed with light
what is the minimum number of weeks of exercise to obtain longer term benefits
6 weeks
how is stretching for neck pain
not good in isolation
needs to be combined with MET
greater benefits from other MT and MET
what is the evidence for traction with neck pain
mechanical tx= no support
intermittent tx= some support with short/intermediate traction with neck and related arm pain, especially with exercise and other CPRs
what is the prognosis for radiculopathy
70% good or excellent outcomes at 2 years
90% had mild symptoms at 5 years
what is CPR for radiculopathy
greater than or equal to 3 LR
less than 54 yr
non dominant UE
looking down does not worsen symptoms
more than 30 degrees of flexion
what is the Rx for radiculopathy
mechanical traction
NO STM
MT and local muscle training
thoracic thrust manipulation
how does evidence favor for modalities with neck pain
lacking, limited, or conflicting
what is the evidence for education/counseling with neck pain
strong
early movement w/out provocation
reassurance of good prognosis and full recovery in most cases
if pt has acute trauma to the neck, what is the best time period for recovery
1st 12 wks, little improvement after 12 months
what is nociplastic pain
altered pain perception without complete evidence of actual or threatened tissue
what is the peripheral patho of nociplastic pain
thinning myelin sheaths
a delta and c fibers get excited easily making it hard to override pain with motion
what is the central patho for nociplastic pain
increased excitability of dorsal horn
loss of descending anti-nociceptive mechanism- less pain control - no endogenous opiate released
how does the nociplastic pain work with somatic convergence in a region
c fibers split and travel 2 vertebrae superiorly and inferiorly
what conditions are related to nociplastic pain
persistent fatigue syndrome
fibromyalgia
LBP
age related jt changes
lateral elbow pain
shoulder pain
migraine
neck pain
what are the S&S for possible nociplastic pain
less than or equal to 3 months of pain
regional or spreading
Pain can not be explained
pain is hypersensitive or allodynia
what criteria if present can be probable nociplastic pain
sensitivity to light, sound, or odor
sleep disturbance
fatigue
cognitive problems
what are ANS S&S for nociplastic pain
pitting edma
decrease sebaceous gland
sweaty hands/feet
coldness/clamminess- decrease peripheral arterial shunting
loss of laterality
increased erector pili muscles
what are test if + can indicate ANS S&S of nociplastic pain
distract jts for 1 min then retest- decrease skin mobility/rolling and increase sensitivity
scratch test- excessive reddening
graphesthesia- cant differentiate drawn letters on skin
what is the general Rx for nociplastic pain
JM
MET
neuroscience education/behavioral therapy
why is JM the best treatment in CNS
stimulates descending inhibitory pain mechanisms- release endorphins
induce presynaptic inhibition
reduce dorsal horn excitability
decrease inflammatory mediators
what is the MET parameters for nociplastic pain
low to moderate intensity global aerobic and resistance
2-3x/wk
30-90 minute sessions
7 weeks duration
what are the benefits of MET with nociplastic pain
endogenous analgesia
helps pt to interpret pain and motion as non threatening
reorganize homunculus
why is neuroscience education/behavioral counseling beneficial for nociplastic pain pts
explain increased sensitivity and misinterpretation to reduce stress and anxiety
transition to adaptive pain coping
what is the prognosis for nociplastic pain
varying degrees of improvement
longer recovery
not full resolution of symptoms
how does WAD occur
acceleration-deceleration event
often strains and sprains
possible concussions
what is the craniovertebral scan for
initial neck direct trauma
what is the most involved structure injuries in WAD
Z jts sprains and muscle strains
what is the most injury prone facet to be damaged by whiplash and why
C2-3
C2 is horizontal on top and transitions to 45 degree facets on the bottom for C3 facets
what should be the scan findings for a pt with L sided Z jt sprain
limited ROM- R RT & SB, FLX (any motion that stretches the damaged tissue)
+ stress test - distraction and PA pressure
- neuro tests
what are less involved structures in WAD
dens fractures
what are S&S of dens fracture because of WAD
splinting, especially with SB because of alar lig pulling on dens
what are the scan findings for a L muscle strain occurring because of WAD
P! with lengthened position for resisted testing
P! in opposite direction of action - R SB/RT and FLX
what are S&S for fx anywhere in the body
trauma hx
splinting
pain with: palpation, compression, vibration/tuning fork, limited ROM with empty/painful end feels, weak and painful, crepitus
possible + neuro test in spine
what are special tests for fx
percussion with stethoscope
CDRs and CPRs for fxs
what is the bone made of
osteocytes
minerals
type 1 collagen
what are the 2 layers of bone
cortical - outer layer
cancellous - inner layer
what is the timing of bone healing
timing varies by innumerable factors
what is the repair phase of healing for bone
1-3 weeks
soft callous or fibrocartilage forms from fibro/chondroblasts
what is the modeling phase of bone healing
4-8 weeks sometimes up to 12
osteoclasts (destroy) cartilage and osteoblasts form bony and hard callous
fracture line no longer visible
what is clinical union and what phase is it in
fracture line no longer visible
modeling phase
when can a Pt start PT after a fx and what is the rehab focused on
4-8 weeks
fracture line no longer visible
more on consequences of prolonged immobilization or other injuries from the trauma (noncontractile)
what is the remodeling phase of bone healing
months to years
conversion of cartilage for more abundant compact bone
what can complicate bone healing
OP
amenorrhea
energy expenditure- stress, sleep, diet
impaired circulation
infection
poor load management
what can complicating factors lead to in a fx
delayed union - slow uniting
non union - never unites
malunion - misalignment
how can a fx be fixed
closed reduction
open reduction
what are the S&S of alar ligamentous injury in WAD
splinting, particularly with SB
possible cord S&S loss of den stability
if the pt has transverse ligament tear, what S&S could they present with and how could they be decreased
splinting
cord S&S - dens allowed to move posteriorly into cord
do manual retraction while stabilizing axis SP to glide atlas posteriorly and away from cord
what does the rim resist
excessive hyperextension
if pt has rim lesion, what can it present with in a scan
splinting with extension due to anterior annulus tears
P! with compression (end plate) and distraction (annulus)
what are the symptoms of WAD
trauma with acute neck and intrascapular referred pain
potential TCN
what are the scan findings for WAD
observation - splinting
ROM - limited with empty and painful end feels in all directions
resisted/MMT- weak and painful in several directions
neuro - possible + findings because of cord
stress - + for involved tissue
why would someone have hypomobility with WAD
due to immobilization/disuse and fibrotic scarring
why would someone have hypermobility with WAD
no prolonged immobilization or fibrotic scarring causing laxity
what is TCN
located at C2-3 jt
interaction of sensory nerve fibers of Trigeminal n and C1-3
inflammation and/or sensitization symptoms of head, face, and neck
may develop to nociplastic pain
in TCN what S&S could be present due to the trigeminal (mandibular) n
tongue- altered taste/tingling
ear- pain/tinnitus/hypersensitivity
in TCN what S&S could be present due to trigeminal (ophthalmic) n
eye- pain, conjunctivitis without red eye, visual deficits
in TCN what are S&S that could present due to trigeminal (maxillary) n
tooth ache/pain
in TCN what are the S&S that could be present due to C1-3 spinal n
head- headache, dizziness, paresthesia
face- pain and paresthesia
jaw- TMJ pain
what nerve can also be affected due to TCN and why
vagus n has nucleus in C3-4
what are the S&S that can be given off due to vagus n involvement in TCN
irregular HR
lack of sweating
dyspnea
nausea
indigestion
other GI S&S
why is balance affected with a concussion or WAD
restrograde branch of trigeminal n goes to cerebellum therefore coordination is affected
what is the general Rx for WAD
POLICED
possibly a soft collar
what are the parameters for nociplastic pain with WAD
body awareness and stabilization exercises
90 minute session
2x/wk
10-16 wks
what are MT and MET that can be done for WAD once outside of acute phase
cervical and thoracic JM/manip
deep neck flexor and scapular stabilizer exercises
