Neck Pain with Associated Joint Mobility Deficits AND/OR Soft Tissue Irritability Flashcards
Common Mid Cervical and Upper Thoracic Joint Mobility Deficits - Common Medical Conditions/Diagnosis
- Facet joint syndrome
- Degenerative disc disease
- OA of the facet joint
Common Mid Cervical and Upper Thoracic Joint Mobility Deficits - subjective
- Central or unilateral pain. Fairly specific (Pin point)
- Limitation in neck motion that consistently reproduces symptoms
- Referred pain associated with facet joint irritation (C4-5,5-6,6-7 most common)
- Commonly aggravated with SB or Rotation to the side and/or extension. “pinching sensation”
Mid Cervical & Upper Thoracic Joint Mobility Deficits - Objective
AROM Assessment in Sitting
* Pain toward side of Sx and/or extension
* Restricted motion and/or pain especially with overpressure (loading of spine)
* Aberrant motions
PROM Assessment in Supine
* Restriction of motion and/or pain similar to AROM assessment
Joint Mobility
* Manual Traction alleviates (unloading of spine)
* Thoracic: Hypomobility and/or pain mid to endr range with PA assessment
* Cervical: Hypomobility and/or pain mid to end range of down slide assessment on side of closing down
Palpation of Joint Structures
* Pain and/or muscle tone with palpation of relevant articular structures (articular pillar)
Soft Tissue Mobility/Flexibility
* May have associated soft tissue tenderness of muscle in vicinity of pain
Neuro
* Negative neuro screen
Mid Cervical & Upper Thoracic Joint Mobility Deficits - Irritability
High:
* Muscle GUARDING before end ranges, AROM and PROM limited
* Very light palpation reproduces symptoms over articulation
* Takes a long time for symptoms to resolve once irritated
Moderate irritability:
* Pain at end ranges of AROM and PROM
* Moderate palpation reproduces symptoms over articulation
* Able to alleviate symptoms when get out of provocative positions
Low irritability:
* Pain with overpressure into end ranges of AROM and PROM
* Deep pressure reproduces symptoms over articulation
* Able to alleviate with change in position
Mid Cervical & Upper Thoracic Joint Mobility Deficits - Intervention
- Education (stay active, downplay imaging)
- Manual therapy
–Thrust and non-thrust mobs to thoracic, cervicothoracic, and cervical spine
– Manual stretching
– Soft tissue mobilizations as needed. - Self ROM - Therapeutic Exercise
– Self-mobilizations, SNAGS
– General stretching and self ROM - Motor Coordination and movement reducation (as needed)
Cervical Spine
Large percentage ____ of asymptomatic patients present with “degenerative changes” (change in signal intensity of disc, posterior disc protrusion, disc space narrowing) and bulging discs. Even those in their 20’s ____
(73-90%)
(73%)
“____ changes” increase as we age
Degenerative
Their is poor correlation between ____ and MRI findings
persistent pain of WAD (neck)
General patient education
- Majority of neck pain resolves spontaneously
- Stay as active as possible within the tolerance of pain
- Downplay MRI and plain films if applicable
- Early conservative interventions improve outcomes
- You have ruled out all the “BAD STUFF”
Education specific to joint mobility
- Joints are generally tight and restricted
- Motion helps to diminish tightness
- Joint mobilizations help to improve mobility and allow you to move more comfortably
Research Summary about Thoracic Thrust Mobilization Techniques for neck pain
- Within session changes in neck motion
- More effective than non thrust techniques
- Favored for short term improvements
- Is as effective as cervical techniques for neck
- No harm in performing thoraic thrust mobilizations
Specific study on Development of a CPR for Thoracic Manipulation in the treatment of mechanical neck pain
6 Variables
* Acute (Less than 30 days)
* Non Radicular (No Sx distal to shoulder)
* Low Fear avoidance beliefs (less than 12)
* Hypomobile thoracic spine
* Hypomobile upper thoracic and cervical (cervical extension ROM less than 30 degrees)
Results not validated but ALL patients benefited
____ or more out of 6 variable for CPR Thoracic Rule provides a ____ probability of succcess
- 4
- 93%
Research Summary about Cervical Mobilization Techniques for neck pain
- Cervical manual mobilizations are effective in improving outcomes for patients with neck pain
- “Cervical manipulation and mobilization produced similar changes. Either may provide immediate- or short-term change; no long term data are available.”
- Minimal difference in outcomes when comparing thrust to non-thrust techniques
Thrust or non thrust produce similar changes
Thrust vs Non Thrust: Thoracic and Cervical on Cervical Effectiveness
Thoracic
* Thrust is more effective than non thrust
Cervical
* Non thrust and thrust are equal
Must consider potential aggravtion of Sx and if not screen properly vascular complications
____ therapy helps to facilitate motion
manual
To maintain gain, what do we need to give patients?
Teach specific exercises
High vs Low irritability Tx
High:
* Motion in non-provacative ranges
* Avoid pain early
Low:
* Motion in provacative ranges
* Move into pain as long as goes away immediately
Mid Cervical and Upper Thoracic Soft Tissue Irritability - Common Medical Conditions/Diagnosis
- Muscle strain
- Myofascial pain syndrome
- Active Trigger points
Cervical and Upper Thoracic SOFT TISSUE Irritability - Subjective
- More towards chronic symptoms
- Pain distribution localized to neck/scapula at area of muscle attachments with possible referral pain familiar to muscle (arm or head). Not as pinpoint
- Unilateral or bilateral
- Symptoms caused by overuse and/or longer periods of loading of tissue (i.e.: static postures)
- Pain affected with “stretching” (either better or worse)
- Sx increase throughout the day
Cervical and Upper Thoracic SOFT TISSUE Irritability - Objective
Posture:
* Poor posture and unable to maintain “ideal”
AROM Assessment in Sitting
* May be restricted motion and/or pain/stretch esp. with motion away of symptoms (stretching)
* Predominant aggravating motion is flexion and side bending
* Aberrant motions
PROM Assessment in Supine
* More PROM than AROM especially with muscles on slack
Joint Mobility
* Normal mobility. May have mm guarding at end range
Palpation/Flexibility
* Pain, symptom reproduction and increased tone of relevant muscles. Presence of trigger points.
Motor Assessment:
- Poor motor coordination and/or endurance
Neuro:
- Negative neuro screen
Trigger point referral patterns for Cervical and Upper Thoracic Soft Tissue
- Suboccipitals
- Erector spinae
- Scalenes
- SCM
- Levator scapula/ Upper Trapezius
Cervical and Upper Thoracic SOFT TISSUE - Irritability
High:
* Muscle GUARDING before end ranges, AROM and PROM limited
* Very light palpation reproduces symptoms
* REFERRAL OF SYMPTOMS with palpation (ACTIVE TP)
Moderate:
* Stretch pain at end ranges of AROM and PROM
* Moderate palpation reproduces symptoms
* MAY HAVE REFERRAL OF SYMPTOMS
Low:
* Stretch pain with overpressure into end ranges of AROM and PROM
* Deep pressure reproduces symptoms
* NO REFERRAL OF SYMPTOMS
Cervical and Upper Thoracic SOFT TISSUE - Intervention
Education
Manual therapy
* Soft tissue mobilization (Instrumented, Manual, Pin and stretch)
* Manual stretching (Static, PNF)
* Thoracic, CT and Cervical non-thrust and thrust mobilization techniques (as needed)
Therapeutic Exercise
General stretching and self ROM
Motor coordination and movement re-education (as needed; especially if more chronic symptoms)
Patient education - Specific to Soft Tissue Mobility
- Muscles are sensitive to activity.
- Motion and stretching helps to desensitize the muscle to activity
- Need to work other muscles to minimize stress on painful muscles (Motor Coordination)
- Specific soft tissue mobilization helps “speed the process along”
Does soft tissue irritability occur in isolation?
No!
- Reduction of joint motion is related to local muscles innervated by that segment
- Relationship between presence of trigger points in the upper trap/erector spinae and cervical dysfunction in mid cervical region
- ALSO, the presence of TP may induce central pain processing centers (central centralization) and treating TP may reduce this central sensitization. More complex than “taut bands in the muscle”
- “Clinicians should include assessment and tx of BOTH MUSCLE irritability and JOINT hypomobility in management of neck pain”
STM as an intervention with neck pain
- Within session changes for chronic neck pain
- STM exercise is better than STM alone to Tx neck pain
- STM superior to US to treat neck and arm pain “mechanosensitvity”
Ther Ex for Soft Tissue Cervical Pain
- Manual therapy helps to facilitate motion and decrease muscle sensitivity
- TO MAINTAIN, patient must be taught specific stretching or self-soft tissue mobilization techniques
- For patients with soft tissue mobility deficits:
– High irritability: Avoid sustained holds into the stretch but more frequently. LIGHT pressure to the muscle
– Low irritability: More sustained holds into the stretch Move into pain as long as goes away immediately - MOTOR RETRAINING OF AGONIST MUSCLE!
No longer thought of as an isolated mechanism or an ____ Tx
- Isolated
When understanding how to implement manual therapy it is best to recognize that often there is not just one way to treat a dysfunction but is truly an integration of:
* education
* encouragement
* focus on positive outcomes
* graded exposure / exercise program to improve both peripheral impairments
* central processing
* coping
