L17: Treatment of cervical mechanical disorders- Articular and neural system

Question 1

What are the 6 aims of physiotherapy management?

Answer 1

1. Educate and assure the patient
2. Resolve pain states articular system muscular system neural system
3. Restore muscle function
4. To restore the patients’ functional/activity status and participation in work and social activities
5. Prevent recurrent episodes of pain
6. To optimise quality of life

Question 2

What are 5 physiotherapy treatment methods?

Answer 2

1. Education and assurance: about the condition, prognosis, self management procedures, functional rehabilitation
2. Manipulative therapy: to decrease pain and restore segmental and regional spinal motion to restore normal function
3. Therapeutic exercise:
   
   • pain management of the spinal segment
   • address muscle impairments linked to the disorder
   • improve neuromotor control of posture, movements
   • restore normal function
   • prevent recurrent episodes of pain
4. Electrotherapy: to assist pain control, inflammation
5. Ergonomics: to reduce undue mechanical overload induced by work practices to prevent recurrence, provision of lifestyle advice

Question 3

What are the 5 factors that the selection in the management of the articular system is based on?

Answer 3

1. Observed movement restriction (pattern? compressive/stretch)
2. Pain
3. Specific condition eg disc (rot.), wry neck (distraction) radiculopathy (traction, lat glide)
4. Acuity of condition, irritability
5. Evidence of mechanosensitivity,

Question 4

What are the 5 conclusions of the patient interciew and physical examination?

Answer 4

1. Provisional pathoanatomical diagnosis
2. Main drivers of symptoms
3. A definitive physical diagnosis
   
   1. Basis for selection of initial treatment techniques
4. Assessment is a progressive process
   
   1. Re-evaluate for effect, progress treatment
5. Established clear and quantitative outcomes
   
   1. measures of pain (VAS/NRS)
   2. measures of functional ability*
   3. physical impairment and physical performance *

Shared decision making (patient and physiotherapist) to determine short and long term goals of treatment

Question 5

What are 3 factors that influence the selection of manipulative therapy techniques?

Answer 5

1. Nature of pain, physical impairment and likely pathology
2. Direction of movement restriction determined in the examination of active and passive movements
3. Neurophysiological/physiological/mechanical expectations of the technique

Question 6

What are 4 manual therapy treatment techniques?

Answer 6

1. Segmental accessory/translatory movements: PAIVMs (related to the direction of movement loss)
2. Segmental physiological movements: PPIVMs
3. Long axis movement (traction) manual, mechanical
4. Combined movements combination of physiological/accessory: eg PAIVM in LF, F

Question 7

What are 2 types of passive accessory techniques (i.e PAIVMs)?

Answer 7

Consider the direction of movement restriction (C, Th Spine)

Question 8

What are 5 types of passive accessory techniques (i.e PPIVMs)?

Answer 8

1. Segmental rotation mobilisation: loss of Rot or LF
2. Segmental lateral flexion: loss of LF or Rot
3. Cervical lateral glide: nerve tissue technique - treatment of painful C5, C6 nerve roots
4. Transverse glide (thoracic region): deficits in thoracic segmental rotation or CT junction restrictions
5. Traction: in relation to NR pathology or general hypomobility

Question 9

What do the 4 treatment grades look like?

Answer 9

Question 10

Selection of technique based on the nature of____

Answer 10

pain

Question 11

What are 3 features of tthe selection of technique based on “severe pain”? What is the pain factor?

Answer 11

Technique should be short of pain production

1. grade (eg III-; iv-)
   
   • a larger amplitude which causes overflow to adjacent structures (but more afferent input)
2. position in range (physiological position of ease, eg if Ext is the position of provocation, the patient may be positioned in Flex)
3. painless opposite direction

Question 12

What are 2 features of tthe selection of technique based on “moderate pain”? What is the pain factor?

Answer 12

Technique should cause no or minor pain

1. grade (eg iv-)
2. position in range (physiological neutral position)

Question 13

What are 2 features of tthe selection of technique based on “non severe, milder pain”? What is the pain factor?

Answer 13

Technique should cause no or minor pain

1. grade (eg iv)
2. position in range (physiological position of restriction

Using the previous example, the patient may now be positioned in slight extension)

Question 14

What are the 3 types in the nature of pathology?

Answer 14

1. Compromise of cervical nerve root (technique should increase size of IV canal)
   
   1. Unilat PA: over Z joint ? NO
   2. Segmental rotation: away from the side of pain (take care of tension on NT)
2. Discal pathology:
   
   • Central PA glide or Rotation technique ie a technique which will have a central effect
3. Z Joint arthropathy
   
   • Unilateral PA’s, segmental LF, segmental rotation ie techniques which will have a more unilateral effect, - usually on the same side as the pain

Question 15

What are the 4 specific pathologies?

Answer 15

1. Nerve root pain (acute) Often traction is indicated in the early stages
2. Nerve root (chronic) responds better to local mobilisation +/- attention to neural tissues
3. Generalised chronic arthritic condition: as with peripheral joints, this condition responds well to larger amplitude movements (gr III)
4. Locked Joint: often a high velocity thrust technique may be required to “unlock joint”
   
   • Most likely effect of manipulative therapy is to induce muscle inhibition

Question 16

What are 2 characteristics about the idiopathic “locked” apophyseal joint (wry neck)? What are 2 most common segements?

Answer 16

Pathology is unknown

1. entrapped or extrapped menisci
2. acute nipping of synovial fringe reactive inflammation, swelling and muscle spasm

Most common segments

1. C1‐2 or C2‐3 (largest meniscii)
2. Older subjects ‐ osteoarthrotic changes

Differentiate between sudden and spontaneous origins of acute wry neck (Z Jt versus disc)

Question 17

What are 3 outcomes of clinical reasoning in the progression of treatment?

Answer 17

Each step of treatment should be guided by the reassessment of outcome measures nominated after the initial assessment

These will include outcomes of:

1. pain,
2. physical impairment and
3. the patient’s functional status

Question 18

What are the 2 aims when examining movements in combination (progression using the principles of combined movements)?

Answer 18

1. Position of maximum ease (severe pain)
2. Position of maximum compromise (mild pain)

Question 19

What are the 2 movements in the examination (progression using the principles of combined movements)?

Answer 19

1. determine the sequence of the combination which is most
2. easing (severe pain) is most provocative (mild pain)

NOT SURE

LF is worst than EXT

Acute: LF away + PAVIM

EXT is worst then LF

Acute: Flexion + PPVIM

****

Question 20

What are the 3 progressions by position in range of the physiological movement (combined movement examination)?

Answer 20

1. position of ease –> severe pain
2. neutral position –> moderate pain
3. position of restriction –> milder pain

In combined movement treatments, treat with either accessory or physiological movement

Question 21

In combined movements, the first movement provides the______. The second movement becomes the______.

Answer 21

neck position; treatment movement

Question 22

What are 3 other methord of progression in the combined movements examination?

Answer 22

1. increase time of application
2. increase grade of technique
3. add a combination of techniques with same mechanical intention

Question 23

What are 4 other pointers for combined movements?

Answer 23

1. Often have to treat locally and regionally eg. C/Th region often hypomobile in association with cervical dysfunction
2. Consider the combination of active movement together with passive mobilisation (MWM – Mulligan)
3. Progression of technique is guided by reassessment of outcome measures
4. Do not persist with treatments that are not achieving the desired outcome

Question 24

What is the clinical reasoning summary from the interview?

Answer 24

Question 25

What is the selection of manipulative therapy techniques look like in this case?

Answer 25

Question 26

What are 5 factors that influence the selection of neural sysem management?

Answer 26

1. Observed movement restriction (pattern? compressive/stretch)
2. Pain
3. Specific condition eg disc (rot.), wry neck (distraction) radiculopathy (traction, lat glide)
4. Acuity of condition, irritability
5. Evidence of mechanosensitivity,

Question 27

What is the evidence of the management of radiculopathy?

Answer 27

Limited evidence to support any specific approaches for management of radiculopathy

Question 28

What are 5 main aims of treatment (which are guided by neural pathology)?

Answer 28

1. Education-reducing symptoms:
   
   1. Postures which relieve pain
   2. Advice about postures which increase strain on the nerve tissue
2. Avoid treatments which reduce intervertebral foramen (IVF) size or compress nerve structures
3. Apply treatments which aim to increase IVF
4. Ensure treatment positions which provoke nerve tissue strain are avoided
5. Consider the role of adjunct medication to reduce the pain state

Monitor patient carefully

Question 29

What are the 4 suggested multipmodal approach to neural pathology?

Answer 29

1. Explanation and advice
   
   1. Pain relief -pharmacological management
   2. Activity modification
   3. Teach pain relieving positions
2. Mobilisation
   
   1. Neural system or surrounding structures
   2. Techniques to open IVF
3. Exercise (ROM, aerobic conditioning- Speed up recovery + pain gating effect)
4. Immobilisation (short-term 2 weeks)

Question 30

What are the 4 treatments for radiculopathy?

Answer 30

1. Relieve pain
   
   1. Pain relieving positions day and night
2. Relieve pressure on nerve root
   
   1. Techniques which open the intervertebral foramen:
      
      1. Traction (usually low cervical levels)
      2. Lateral flexion or rotation PPIVM techniques away from side of pain
      3. Lateral glide (Contralateral)
3. Gentle neurodynamic techniques-distal components only if neurological status is stable
   
   1. Neurodynamic exercises: Low reps (can be highly aggravating
      
      1. Might not give HEP until certaim
      2. Only give 1-2 reps
4. EPAs

Question 31

What are the 4 considerations for the treatment for mechanosensitivity?

Answer 31

Consider irritability! If without radiculopathy….

1. Neurodynamic (nerve gliding) techniques
   
   1. Lateral glide? + ULNT positions of arm
   2. ULNT components (median, radial, ulnar)
   3. Start with slider techniques (think of ‘flossing’ nerve)
   4. may progress to tensioning in chronic
2. Generally avoid positions which tension the nerve
3. Proceed with caution, much less vigorous than muscle stretches
4. Gentle home exercise
   
   1. monitor carefully

Question 32

What are 2 considered techniques if MSK management/treatment (neurodynamic exercises) is indicated? What are other considerations?

Answer 32

1. Directed to surrounding tissues
2. Directed to the nervous system
   
   1. Sliding techniques (Sliders)
   2. Tensioning techniques (Tensioners)

Consider pain mechanisms in operation; history, severity and ‘irritability’, stages of healing associated with the particular pathology, signs and symptoms, results of medical investigations

Question 33

What are the 5 steps in the application of neurdynamic techniques?

Answer 33

1. Start with gentle technique
   
   • ? Surrounding structures 1st
2. Only a few reps, NOT like exercise program
3. Assess the effects of the treatment
4. Progress slowly and carefully to avoid aggravation of sensitive nerve tissue
5. Outcome measures?

Question 34

What is a cervical (neurodynamic) contralateral lateral glide (directed to the surrounding structures)?

Answer 34

Stabilise shoulder + lateral glide of neck (start with arm on chest)

Progression: Bring patient’s arm from chest to side of body

Question 35

What is a tensioning neurodynamic technique (directed to the nervous system)?

Answer 35

Possible to put nerve on full tension

Question 36

What is a sliding neurodynamic technique (directed to the nervous system)?

Answer 36

Won’t put the nerve on FULL tension

Question 37

What are 2 clinical assumptions about tensioning neurodynamic techniques?

Answer 37

Question 38

What are 2 clinical assumptions about sliding neurodynamic techniques?

Answer 38

Question 39

What does the tensioning VS sliding technique look like?

Answer 39

Question 40

What are the 4 manipulation therapy techniques?

Answer 40

1. accessory movements
2. physiological movements
3. Long axis movement
4. Combined movements

• PPIVM: LF away from painful side OR Rot away
• Traction
  
  • (low cervical) –> in flexion (2 pillows)
  • (upper cervical) –> in more extension
• Physical activity (eg.. Walking upright) = good (but must support arm)
• Pain medication
• Teach sleeping positions

Question 41

What are 3 systems that can cause pain?

Answer 41

1. Articular system
2. Muscle system
3. Neural system

Question 42

What are 3 main and general considerations in manipulative therapy (for articular system)?

Answer 42

1. Direction of movement restriction determined in the examination of active and passive movements
2. Nature of pathology
3. Guided by re-assessment