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PHTY3260 > L16: Management of cervical mechanical disorders > Flashcards

L16: Management of cervical mechanical disorders Flashcards

1
Q

What is the summary of musculoskeletal neck pain?

A
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2
Q

What are 6 reviews of assessment?

A
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3
Q

What are the 4 neck pain disorders?

A
  1. Mechanical neck pain – 80-90%
    1. Radiological imaging =/ specific pathoanatomical diagnosis;
    2. No positive lab tests
      1. occupational induced neck pain
      2. postural strain – overload on cervical structures
      3. degenerative joint disease (Z joint or disc)
  2. Nerve root compression irritation (lateral or central canal stenosis - disc, osteophytes)
  3. Trauma induced neck pain
    1. motor vehicle accident
    2. sport, fall, blow to head
  4. Non mechanical neck pain – AS, RA, tumour, congenital
  5. disorder
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4
Q

What are 3 types of mechanical neck pain as neck pain disorders?

A

80-90%

  • Radiological imaging =/ specific pathoanatomical diagnosis;
  • No positive lab tests
  1. occupational induced neck pain
  2. postural strain – overload on cervical structures
  3. degenerative joint disease (Z joint or disc)
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5
Q

What are 2 types of nerve root compression irritation as neck pain disorders?

A

lateral or central canal stenosis - disc, osteophytes)

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6
Q

What are 2 types of trauma induced neck pain as neck pain disorders?

A
  1. motor vehicle accident
  2. sport, fall, blow to head
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7
Q

What are 4 types of non mechanical neck pain as neck pain disorders?

A
  1. AS
  2. RA
  3. tumour
  4. congenital disorder
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8
Q

What are the levels of evidence of cervical management?

A
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9
Q

What are the challenges of cervical management? What is the truth? What are 6 types?

A

The label ‘mechanical neck pain’ suggests a homogeneous condition

Mechanical neck pain disorders are heterogeneous

  1. neck pain
  2. neck pain and headache
  3. neck and arm pain
  4. dizziness, light headedness
  5. visual disturbances
  6. other sensory disturbances
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10
Q

What are 6 different heterogeneous mechanical neck pain disorders?

A
  1. neck pain
  2. neck pain and headache
  3. neck and arm pain
  4. dizziness, light headedness
  5. visual disturbances
  6. other sensory disturbances
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11
Q

What are 3 neck pain types?

A
  1. primarily nociceptive
  2. neuropathic pain
  3. augmented pain processing (peripheral or central sensitization)
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12
Q

What are 6 challenges of neck pain management?

A
  1. Be very aware of strongly differing schools of thought within the profession (state and national differences)
  2. Current moves to reduce the emphasis on manual therapy and specific exercise and increase pain education
  3. Promoted strongly on social media
  4. Don’t ignore the advice of experts in the field
  5. Consider what your patient wants
  6. Look at the evidence and be critical of it
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13
Q

What are 6 differences in patients with mechanical neck pain? What is the aim?

A
  1. The segmental source of pain is variable between patients
  2. The degree and nature of articular pathology varies between patients
  3. The nature and degree of muscle impairment varies between patients
  4. Impaired function of the cervical somatosensory system may or may not feature in the disorder
  5. Functional and work stressors vary between patients
  6. Psychological features may or may not be moderators of the condition

The aim is to determine what are the key drivers in the patient’s condition

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14
Q

What are 4 ways that neck pain is a heterogeneous disorder?

A

There has been strong recognition for better classification systems for neck pain to improve outcomes and better estimate prognosis

  • Supportive workplace and having control over work = better outcomes for MSK injuries
  1. Treatment based classification systems
  2. Clinical characteristics based classifications
  3. Movement and symptom response based classification systems
  4. Pathophysiologically based classification systems

Sufficient evidence for the application of specific physiotherapy modality or aiming a specific patient subgroup is not available

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15
Q

Patho-anatomical diagnosis has a limited contribution. Pathophysiological features (sensory, motor, sensorimotor and psychological) and _______ can clearly be identified. Identification and assessment of these features directs specific management to specific problems. Emphasis on ______ , assessment and analytical skills. _______ to the management of neck pain disorders

A

functional stressors; clinical reasoning; No recipe approach

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16
Q

What are the 3 WHO ICF domains in the assessment that provide comprehensive information?

A
  1. impairment (and pain)
  2. activity limitation
  3. participation restriction
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17
Q

What are the treatment aims when assessing and managing the individual with neck pain? What are the outcome measures?

A

Treatment aims to reduce pain and reverse impairment. To be effective, must remove the limitations to the patient’s activity and the restrictions to participation

Outcome measures: relate to pain, activity and participation

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18
Q

The evidence indicates that a ______ approach to treatment of neck pain disorders is superior to single modality approaches

A

multimodal

19
Q

What are 4 features of the multimodal physiotherapy program?

A
  1. Pain management (dizziness, visual disturbance…etc)
  2. Rehabilitate physical impairments
  3. Restore function
  4. Restore patient’s participation in work, home and recreational activities
  • In collaboration with the patient
  • Guided by identified key drivers
20
Q

What are 3 characteristics of “1. pain management” of the multimodal physiotherapy program?

A
  1. Explanation, education, assurance, ergonomic modifications
  2. Manual therapy (General mechanical pain gating effects), specific therapeutic exercise, neurodynamic management
  3. Adjunct agents – electrophysical agents
21
Q

What are 4 characteristics of “2. rehabilitate physical impairments” of the multimodal physiotherapy program?

A
  1. Manual therapy and segmental active exercise
  2. Specific motor relearning and graded therapeutic exercise
  3. Sensorimotor retraining
    • If too irritable, painful –> unable to do movements (eg. eye tracking)
  4. Neurodynamic mobilisation
22
Q

What are 3 characteristics of “3. restore function” of the multimodal physiotherapy program?

A
  1. Specific skill training
  2. Graded therapeutic exercise
  3. General exercise
23
Q

What are 3 characteristics of “4. restore participation” of the multimodal physiotherapy program?

A
  1. Graduated return to work/sport
  2. Ergonomic modifications
  3. General lifestyle advice
24
Q

What are 4 characteristics of “patient must be an active particpant” of the multimodal physiotherapy program?

A
  1. Self management exercises
  2. Enhance active coping
  3. Encourage
  4. Support
25
Q

What is goal setting for cervical management? What are long term VS short term goals?

A

Goal setting – specific to patient’s context

  • have a clear understanding from the patient of their expectations of treatment
  • model goals on these expectations; discuss collaboratively with the patient

short term and progressive goals:

  • pain relief and restoration of function, activity/participation achievable incremental steps

long term goal:

  • prevention of recurrence
26
Q

What are 8 characteristics of “explanation, education and assurance” of the multimodal physiotherapy program?

A
  1. mechanism of neck pain and provisional diagnosis
    1. Use lay ‘non-mystical’ language, no jargon, no fear inducing terms
  2. relationship of neck pain to work practice, postures, movements, activities (as identified in patent interview)
  3. rationale of treatment
  4. relationships of impairments to pain and pain relief (demonstrated in the physical examination)
  5. the benefits of staying as active as possible
  6. reduce any anxiety, fears, unhelpful beliefs
  7. assess coping skills (offer encouragement to poor ‘copers’)
  8. patient must be an active participant in management
27
Q

What are 3 characteristics of “posture, ergonomuc and work practice advice” of the multimodal physiotherapy program?

A
  1. Understand patient’s work, sport or recreation requirements/practices/postures
  2. Evaluate the presence of any adverse work, sport, recreation practices or postures which may be causing, contributing or perpetuating the pain state
  3. Modify work practices in collaboration with the patient to achieve short and long term outcomes
28
Q

What are 3 characteristics of “adressing pain and impairment” of the multimodal physiotherapy program?

A
  1. Loss of movement and painful segmental joint dysfunction
    1. Manual therapy – passive mobilisation or MWM
    2. Specific active segmental exercises
  2. Refer selection of MT techniques
  3. Based on:
    1. Intensity and nature of pain
    2. Direction of movement loss
    3. Any other directives from suspected pathology
29
Q

What are 2 characteristics of “loss of movement and segmental joint dysfunction- manual therapy” of the multimodal physiotherapy program?

A

Treat

  1. local joint dysfunction
  2. regional joint dysfunction eg C/Th; Th region
    • Go down to T3 even when assessing cervical (eg. headache) = clear adjacent joints

Note: painfree application of manual therapy techniques

30
Q

What are 3 characteristics of “active exercise to reinforce effect of MT” of the multimodal physiotherapy program?

A
  1. Specificity in active exercise (cf MT techniques)
    1. segmental guidance – F-E; LF; Rot
    2. regional specificity (eg C1-2 rotation; C/Th)
    3. self assisted active exercise (strap, towel edge)
  2. Acute pain: consider relief of compressive load of head – 4 pt kneel; prone on elbows; supine
  3. Facilitate with eye movement
    • If having difficulty performing the movement (can use eyes to lead movement with eyes –> look first then move)
31
Q

What are 3 characteristics of “within a treatment- manual therapy or specific exercise first” of the multimodal physiotherapy program?

A

Change in symptoms with posture = muscle system involved

No change in symptoms with posture = articular system (more likely)

32
Q

What are 18 characteristics of “addressing pain and impairment: effect of pain and injury on the motor system” of the multimodal physiotherapy program?

A
  1. Pain induces immediate changes in cervical muscle function
  2. Complex array of cervical neuromuscular adaptation
  3. Changes in cervical motor control
  4. Peripheral adaptations in the muscle itself
  5. Specific impairment in the neck flexors and extensors axio-scapular muscles
  6. address any adverse postural loading, teach neutral posture
  7. focus on activating the deep neck and axio-scapular muscles (low load exercises)
  8. retraining tonic endurance capacity of deep neck and axio-scapular muscles (low level endurance training)
  9. integration into function –task specific postural exercise
  10. co-contraction exercise (deep flexors and extensors)
  11. re-education of movement patterns
    • neck and girdle including task specific training
  12. Strength and endurance training
  13. Therapeutic exercise commences immediately in the
  14. rehabilitation process, with manual therapy techniques
  15. Exercise should not provoke neck pain
  16. Individual exercises are designed to address the specific changes identified in muscle function
  17. Muscles are trained with specific exercises and within a functional and task specific context
  18. Repetition is essential in the learning process to establish or reestablish appropriate movement and muscle control
33
Q

What are 3 characteristics of “addressing pain and impairment” of the multimodal physiotherapy program?

A
  1. Cervical kinaesthetic sense
  2. Balance
  3. Eye movement control
    • Follow with eyes (finger or pencil)
34
Q

What are 3 characteristics of “assessment of the individual patient” of the multimodal physiotherapy program?

A
  1. Retrain any components found to be impaired
  2. Begin training at the level of assessed impairment
  3. Introduce progressively
35
Q

What are 6 characteristics of “adjunct therapy of the electrophysical modalities?

A
  1. no evidence that electrophysical modalities, applied as the sole principal therapy, are effective
  2. Heat can provide effective comfort (note: no side effects)
    • Calm and relax patient + reduce local muscle spasm
  3. TENS (Or electrical stimulation) may have an effect as part of a pain management program
  4. Acupuncture –some evidence in cervicogenic headache
  5. EMG biofeedback can be effective in the relearning process of muscle control
  6. Taping – pain relief; facilitatory taping, rigid tape –> reposition scapula
36
Q

What are 9 characteristics of “all patients must receive individualized *recorded advice about self help procedures and specific exercises” of the self help and home exercise programs?

A
  1. Customize for the patient * specific to context- phone, app, email
  2. Ensure program is realistic; discuss time for exercise
  3. Postural correction – describe, cues
  4. Instructions for each exercise: joint mobilisation (ROM) and muscle training exercises
  5. Provide illustrations (stick figures, use their phone )
  6. Provide precise dosage (they can manage easily initially)
  7. Instructions for work practices/postures
  8. Sleeping position (as indicated)
  9. Use of heat etc at home if required
37
Q

What are 9 characteristics of “address activity limitation and participation” of the self help and home exercise programs?

A
  1. Advise on task modifications to protect neck (see MAIC booklet)
  2. computer work - retrain posture and work practices
  3. lifting, carrying
  4. bench, production work advice re loads, correct technique
  5. gym work; importance of maintenance of neutral spinal posture
  6. Advise on patient’s particular functional activities
  7. Maintenance of general activity – walking, discuss with patient
    • Eg. get patient to walk –> pain gating effects + maintain general conditioning
  8. Management
    • Esp. posture related problems
38
Q

What are 7 factors to consider or management? What are the aims and goals? What are 3 characteristics of reflective practice?

A
  1. Expectation of outcomes
  2. Aim and goal: to achieve the best possible outcome for the patient
  3. If patient not responding to physiotherapy management:
  4. Reflective practice
    1. ask yourself what you have missed, reassess, treat as a new patient
    2. insufficient expertise to manage the difficult patient? – refer on to a more experienced and specialised physiotherapist eg Musculoskeletal Physiotherapist; Specialist Musculoskeletal Physiotherapist (FACP)
    3. have you provided sufficient treatment - Length of treatment, number of treatments
  5. Monitor outcomes
  6. Length of time to change muscle function
  7. Is pathology/pathophysiology too great to manage by physiotherapy alone?
39
Q

What are 4 characteristics of “Is pathology/pathophysiology too great to manage by physiotherapy alone?” as factors to consider for management?

A
  1. Neuropathic pain – collaborate with GP or specialist for appropriate pain management
  2. Significant trauma – pain and dysfunction too severe and requires other interventions as well
    1. Appropriate medication
    2. Facet joint injections
    3. Neurotomies
  3. Pathology – significant neuropathic pain and neurological signs with confirmed compression on a nerve root, needs surgical opinion
  4. Psychological/psychosocial factors – are they impeding rehabilitation?
    1. post-traumatic stress – refer health psychologist
    2. work place factors
40
Q

What are 5 “multiprofessional treatment and research” for management?

A
  1. Medical – GP, Orthopods, Neurosurgeons, Rheumatologists, Pain specialists Interventional Radiologists
  2. Physiotherapists
  3. Health Psychologists (Note trauma induced cervical spine problems eg distress following a motor vehicle crash)
  4. Occupational Health Physiotherapists or OTs
  5. Ergonomists
41
Q

What are 5 general factors to consider for management?

A
  1. chronicity of condition does not necessarily mean a poor outcome
  2. concept of maintenance physiotherapy to augment self management
  3. Work collaboratively with the patient and other health professionals
  4. Do not leave the patient ‘out on a limb’. If you cannot assist, refer on to appropriate practitioner
  5. Psychosocial factors do not necessarily mean you should use a hands off approach
42
Q

Skilled physiotherapy management can enhance the ______ for most patients with neck disorders

A

quality of life

43
Q

Every patient must be treated as an individual, they will present with an unique set of ______, ______ and ______.

A

symptoms, impairments, activity limitations

44
Q

What are 6 characteristics of future research?

A
  1. sub-categorisation of patients
  2. better recognition of responders and non responders
  3. better prognostic indicators for a variety of neck disorders
  4. better knowledge of treatment dosages
  5. better knowledge of the effects of a multidisciplinary approach
  6. more basic physiological research to better understand the physiological effects of interventions and relevance to pain and function

PHTY3260 (27 decks)

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