L9 clinical syndromes Flashcards
neck pain epidemiology
lifetime = 70% people <1% chance due to serious medical condition WHO burden of disease 1. LBP 2. MDD 3. iron - def anaemia 4. neck pain
1-11% have activity limiting neck pain
diagnositic triage
Cord compression symptoms / Cervical Myelopathy
Hyperreflexia, (+) Babinski signs
Numbness in hands / feet
Weakness in legs (difficulty walking) & arms (difficulty using hands)
Ataxic gait
Bilateral limb pain
Rheumatoid Arthritis – why?
Occipital numbness/paraesthesia, headaches, vertigo, tinnitus, visual disturbances
Cervical Artery Dysfunction (CAD)
Vertebrobasilar insufficiency (VBI) + Carotid artery dysfunction
possible causes
pain / dysfunction
trauma = whiplash
WAD
ligt strain muscular strain
degen spondylosis spondylolisthesis facet joint arthritis cervical myelopathy PIVD
inflammatory
ankylosing spondylytis
RA
mechanical neck pain postural neck pain cervicogenic headache acute locked neck cervical rib TMJ dysfunction
CAD
torticollis
infections
tumours
whiplash biomechanics
hyperextension
hyperflexion
accelerations deceleration mechanism of energy transfer to the neck
may result from motor vehicle collisions
impact may result in bony or STI
may lead to WAD
whiplash possible injuries
Possible injuries:
Ant. Long. ligt sprain
Disc pathology – cervical & lumbar (shear)
Articular facet capsule sprain
Nerve root traction injury (especially side-on impact)
Muscle strains – SCM, longus colli, Scalenes etc.
Retropharyngeal haematoma
Intraoesophageal haemorrhage
Cervical sympathetic chain reaction
Post Concussion syndrome (20mph) VBI – Temporary vertebral artery ‘spasm’ Fracture Fracture / Dislocation Cord injury Sternal contusions Vascular traction e.g. aorta
WAD symptoms
neck pain / stiffness headache pain dizziniess altered sensation or numbness motor weakness visual symptoms dysphagia TMJ pain concentration difficulties
WAD classification
Grade 0
No complaint about the neck.
No physical sign(s).
I
Neck complaint of pain, stiffness or
tenderness only.
No physical sign(s).
II
Neck complaint AND
musculoskeletal sign(s).
Musculoskeletal signs include
decreased range of motion and point
tenderness.
III
Neck complaint AND
neurological sign(s).
Neurological signs include decreased
or absent deep tendon reflexes,
weakness and sensory deficits.
IV
Neck complaint AND
fracture or dislocation.
SIRA acute WAD guidelines
predictors of recovery decrease initial neck ROM and initial cold hyperalgesia are predictive of ongoing disability sensation of pain and time to pain on application of ice to the skin - appropriate clinical test to identify cold hyperalgesia - cold pressor test
postural neck pain
KYPHO-LORDOSIS POSTURE –
Consequences for Cervical Spine
mild to mod pain levels SE AM - ok EOD - worse repetitive tasks stretching massage
PE ROM PPIVMs PAIVMs PNF muscle length tests muscle control DNF
consider monitor height desk height position in chair phone mouse lumbar support break periods
acute locked neck
sudden onset
sudden movement - instant pain
AM
pt stuck in side flexion +/- flexion - position of ease
C2/3
all movements paib + regional spasms
meniscoid entrapment /entrapment in facet joints
cervical spondylosis
Usually > 50yrs Primarily C5-7 Cause unknown trauma overuse genetics Lateral canal stenosis can cause radiculopathy Degeneration can be painless symptoms may be sudden particularly after trauma
clinical pattern
Central / unilateral neck pain +/- arm pain +/- radiculopathy
Pain worse EOD
Stiffness worse a.m.
PAIVM – hypo not reactive
LOCALISED HYPOMOBILITY – especially low cervical and upper thoracic
headache classification
Migraine (most common): 4-72hrs builds to crescendo headache before neck pain photophobia aura may precede Tension-type bilateral tightening pain not aggravated by physical activity no associated symptoms Cervicogenic: 14-18% of chronic HA Cluster: episodic (occurring in cycles) or chronic; from 7 days to 1 year. etc
cervicogenic headache
Unilateral or one side dominant
Side consistency
Neck / suboccipital pain
Neck pain before HA (migraine opposite)
Most commonly moderate
other symptoms e.g. nausea, dizziness or visual probs but not dominant symptoms
Lacks a regular temporal pattern - precipitated by sustained neck postures / movements
History of trauma / postural strain / degeneration
Reduced functional ROM
Is Physical Exam discriminatory for CHA vs. Migraine vs. non-headache? Painful segmental dysfunction C0-C3 ↓ AROM – flex/ext Muscle tightness ↓ DNF muscle control Static posture not indicative: FHP older group Zito et al (2006))
High level evidence (RCT) for
multimodal physiotherapy
Intervention
cervical disc dysfunction
Work hx – prolonged cervical flexion
cumulative (deskjob): microtrauma
traumatic: macro / single incident e.g. RTA
Disc herniation usually in degenerating disc
Most common C5/6, C6/7 & C4/5
Often just causes pain with no radiculopathy
usually unilateral
if radiculopathy – may be chemical irritation of herniation not mechanical pressure
Relief of pain with traction
cervical radiuclopathy
Pain in a radicular pattern in one or both upper extremities related to compression and/or irritation of one or more cervical nerve roots.
Frequent signs and symptoms include varying degrees of sensory, motor and reflex changes as well as dysesthesias and paresthesias related to nerve root(s) without evidence of spinal cord dysfunction (myelopathy)
radiating pain in the arm with motor refelx /sensory changes as parasthesiae or numbness provoked by neck postures / movements
C7 = most common
soft disc vs spondylosis
soft disc = single level inflammation interleukins and prostaglandin majority spontaneously resolve spondylosis uncovertebral joint degeneration multiple levels common
natural history CRad
CRad due to Disc
Substantial improvements occur within 12-16/52
Time to complete recovery ranges from 2-3 yrs (83%)
Wong et al 2014
55% recovered at 6 & 12/12 (n=61)
Sleijser‑Koehorst et al 2018
90% have no or mild symptoms after 4-5yrs
20% did not improve surgery Radhakrishan et al 1994
Recurrence – 12.5% in 1-2yrs Honet & Puri 1976
Limited studies supporting any optimal duration of conservative treatment prior to surgery evidence-based conclusions cannot be made
clinical prediction rule CR
Diagnostic criteria: Cluster of four items (3/4) Positive ULNT1 Positive Spurling’s A test Limited cervical rotation to affected side (<60degs) Positive distraction test
LR Point estimates:
3 tests = 6.1 (95% CI 2.0-18.6)
4 tests = 30.3 (95% CI 1.7-538.2)
diagnostic criteria CRad
SRv - Thoomes et al 2017
Rule in
\+ Spurling’s test
\+ Supine Distraction
\+ Arm Squeeze test
High diagnostic accuracy: Sn 96%, Sp 91-100%
Gumina et al 2013
Rule out
- ULNT 1*
- Arm Squeeze test
APTA Guidelines Recommended tests - Wainner’s CPR + Valsalva Cx ROM PSFS PPT Blanpied et al 2017 NASS Guidelines NPRS NDI Bono et al 2011
Dutch PT Guidelines
Recommended tests – ULNT 1, Spurling’s, Supine Distraction test
Report findings to GP and discuss Rx
NPRS
PSFS and activity limitations
ax chronic NeuP in primary care
Consensus on Diagnostic processes
Categorisation of Pain mechanism Neuropathic / Nociceptive pain
Sensory tests: Touch, pinprick, thermal & vibration
Identify Underlying aetiology
Pivotal role for GPs
Early identification & Management
Triage for appropriate Rx strand
Mixed Pain
Lack of response to Nociceptive analgesics Neuropathic pain may be primary
srugical review criteria for CR
Sensory symptoms (radicular pain and/or paraesthesia) in dermatome corresponding to involved cervical level
AND
Motor deficit OR reflex changes OR positive EMG
AND
MRI OR Myelogram with CT – concordant
AND
At least 6/52 of conservative Rx
Exception = Major motor deficit after acute injury
Sensory symptoms (radicular pain and/or paraesthesia) in dermatome corresponding to involved cervical level AND Positive response (80% improvement or 5 VAS pts) to Selective Nerve Root Block (SNRB)
cervical red flags =
Cervical red flags = Craniovertebral instability Cord compression / Myelopathy, CAD / VBI
Additional syndromes to consider = WAD & CHA
