Other - Special tests and CPR's for Cervicothoracic (may be also covered in other sections)

Question 1

What are the high-risk Canadian C-spine factors?

Answer 1

1) age >/=65yo
2) Parasthesias in extremities
3) Dangerous mechanism of injury

If any of these are positive, a radiograph should be done.

Question 2

What are considered dangerous mechanisms of injury according to the Canadian C-spine rules?

Answer 2

1) Fall from height >1m or 5 stairs
2) MVA at speeds > 60mph or involving rollover or ejection
3) Bicycle collision
4) Motorized recreational vehicle accident
5) Axial load to head

Question 3

The Canadian C-spine low risk factors allowing safe assessment of ROM are:

Answer 3

1) Simple rear-end collision
2) Able to sit in ER
3) Ambulatory at any time
4) Delayed onset of neck pain
5) Absence of mid-line tenderness

If clear, is patient able to actively rotate head to 45 degrees to each side? If so, no radiograph.

Question 4

What are the clinical prediction rules for cervical radiculopathy? Studied by whom?

Answer 4

Wainner, 2001
CPR for cervical radiculopathy
1) UNLT 1 (median nerve bias)
2) Cervical rotation <60 degrees
3) + distraction relieves symptoms
4) + spurlings
\+LR 9.6 for 3/4 and 30.3 for 4/4

Question 5

What is the general progression of cervical spondylosis?

Answer 5

1) Neck pain
2) Neck pain with proximal referral
3) Radicular pain
4) Myelopathy

Question 6

List the 2 key depression questions:

Answer 6

1) “Over the last 2 weeks, have you felt down, depressed, or hopeless?”
2) “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”

Sn 96%, Sp 57%

Question 7

Signs/Symptoms of cervical myelopathy?

Answer 7

1) Neck pain, rheumatoid arthritis, dizziness
2) Radicular arm pain
3) May have only BIL LE symptoms (no UE)
4) Bowel/Bladder dysfunction
5) + Hoffman’s and Babinski’s reflex
6) Hyperreflexia (UE & LE), + clonus or sensory changes
7) Multisegmental weakness &/or sensory changes
8) Intrinsic wasting & sensory disturbance of the hands
9) Loss of dexterity
10) Wide-based unsteady gait

Question 8

Mechanical verses systemic causes for cervical myelopathy

Answer 8

Mechanical causes:

1) Trauma (ligament instability, fx)
2) Spinal cord compression
3) Degenerative changes
4) Bulging discs, thickened ligamentum flavum
5) RA with subsequent atlanto-axial subluxation

Systemic causes:

1) MS/ALS
2) Guillain-Barre
3) Multifocal motor myopathy

Cervical myelopathy is the most common cause of para- or quadraperesis

Question 9

Signs and symptoms of neoplastic (cancer) conditions:

Answer 9

1) Age over 50 years
2) Previous history of cancer
3) Unexplained weight loss
4) Constant pain, no relief with bed rest
5) Night pain

Question 10

Spinal fracture screening:

Answer 10

1) Major trauma, such as MVA, fall from height, direct blow to C-spine w/o proper imagining clearance
2) Severe limitations
during neck AROM in
all directions

Question 11

Cervical ligamentous instability screening:

Answer 11

1) Occipital HA and numbness
2) Cervical muscle spasm
3) Severe limitations in C-spine AROM in all directions
4) Signs of cervical myelopathy

Question 12

Inflammatory or Systemic Disease screening:

Answer 12

1) Temperature >100°
2) BP > 160/95 mmHg
3) Resting pulse rate >100 bpm
4) Resting respiration >25 bpm
5) Fatigue

Question 13

Treatment-based classification levels for neck pain made by PT:

Answer 13

1) First level - Is pt appropriate for PT management (red flags cleared) - referral and or consult with medical specialist; substantial functional limitations that interfere with ADLs; Dificulty concentrating at work, driving, reading for a prolonged period of time, or sleeping; NDI not validated - NDI>20%
2) Second level - (red & yellow flags cleared); What level of acuity (based on level of disability) - modification of treatment and/or consultation with psychological or vocational specialist; Able to perform most ADLs without difficulty; Unable to perform demanding or prolonged physical activity, especially when attempting complex tasks; NDI not validated - NDI<20%
3) Treatment based classifications! What treatment should be used?

Question 14

Name the Treatment-based classifications for the neck. What author is primarily associated with them?

Answer 14

Author - Childs
TBC:
1) Mobility
2) Headache
3) Pain Control
4) Centralization
5) Exercise & Conditioning

Question 15

For Mobility:
What are the exam findings?
What are potential interventions?

Answer 15

For Mobility:
Exam findings:
1) Recent onset of symptoms (<60 years old)
3) No signs of nerve root compression or symptoms distal to the elbow

Potential interventions:
1) Manipulation/mobilization of the
cervical or thoracic spine
2) Neck muscle strengthening

Question 16

For Headache:
What are the exam findings?
What are potential interventions?

Answer 16

For Headache:
Exam findings:
1) Chief complaint of headaches accompanying neck pain (from Sjaastad)
- unilateral HA (100% sensitivity)
- HA that starts in neck (100% sensitivity)
- HA aggravated by neck movements/postures
- HA reproduced with palpation upper cervical (C0-C3)
- Neck ROM restricted
2) Headache affected by neck movement
3) No history or signs of migraine

Potential interventions:

1) Manipulation/mobilization of the cervical spine
2) Strengthening of the cervical deep neck flexors
3) Scapular muscle strengthening

Question 17

For Pain Control:
What are the exam findings?
What are potential interventions?

Answer 17

For Pain Control:
Exam findings:
1) Recent, traumatic onset (e.g., whiplash)
2) High pain and disability scores
3) Intolerance for most activities

Potential interventions:

1) Cervical mobilization
2) Active range of motion
3) Avoid cervical immobilization

Question 18

For Centralization:
What are the exam findings?
What are potential interventions?

Answer 18

For Centralization:
Exam findings:
1) Signs of nerve root compression or symptoms distal to the elbow
2) Peripheralization/centralization of symptoms with neck movements
3) Diagnosis of radiculopathy

Potential interventions:

1) Mechanical or manual traction
2) Repeated movement (e.g., retraction) to centralize symptoms

Question 19

For Exercise and Conditioning:
What are the exam findings?
What are potential interventions?

Answer 19

For Exercise and Conditioning:
Exam findings:
1) Longer duration of symptoms (>30 days)
2) No signs of nerve root compression
3) Lower pain and disability scores

Potential interventions:

1) Neck muscle strengthening
2) Upper extremity strengthening exercises

Question 20

The Hoving et al. article Evidence in Mobilization lists 3 specific inclusion criteria & eligible subjects are randomized into 3 groups. What are the 3 inclusion criteria? What are the 3 randomized groups?

Answer 20

What are the 3 inclusion criteria?

1) Non-specific neck pain > 2 weeks duration
2) Age >70
3) No prior neck surgery

The 3 randomized groups:

1) Manual therapy (mobilizations - 6 sessions)
2) PT (active & postural exercise, stretching, relaxation, traction, & modalities - 12 weeks)
3) Continued care (advice from GP, educational booklet, medication)

Question 21

Results of Hoving study: Evidence for Mobilization in notes pt 351-2

What additional information was found (money)

Answer 21

Manual therapy had the best “clinical success” (patients asked if if they were completely recovered or much improved)
Manual PT =63.8% - cheapest treatment $402
Standard PT =50.8% - middle treatment expense $1167
GP =35.9% - most expensive treatment $1241

Question 22

Walker article (reading 11/13 & in notes pg 352-3)
Effectiveness of Manual PT and Exercise for Mechanical Neck Disorders (MND)
- What are inclusion/exclusion criteria?
- Interventions?
- Results?
- Validation?

Answer 22

Inclusion/exclusion criteria
Inclusion: a primary complaint of neck pain, with or without unilateral UE symptoms; age greater than 18; a neck disability index (NDI) score >=10 points; and a composite visual analog scale (VAS) pain score >=30 mm
Exclusion: central spinal stenosis (n=3) & cancer (n=1); whiplash injury within past 6 wks; hx of spinal tumors, spinal infection, cervical spine fx, or previous neck surgery; pending legal action regarding their neck pain; bilateral UE symptoms; or 2 positive neurologic findings at the same nerve root level

Interventions: patients followed for 1 year

• Manual PT & exercise (manual techniques (manip, mobs, muscle energy; HEP; stretching, strengthening, neural mobs)
• Minimal intervention (control; pt. education, encourage neck movement and ADLs, HEP - cervical rotation ROM, continue medication use)

Results
Manual PT and exercise (MET) showed better outcomes and decreased NDI scores by 10 points.
The minimal intervention (MI) group improved, but only showed a decreased NDI scores by 5 points.
Impairment-based manual therapy & exercise provides better ST & LT outcome for MND patients. There was no difference in outcome for patients received cervical manipulation compared to mobilization.

Validation
The NDI has high test-retest reliability, good concurrent validity with the McGill Pain Questionnaire and patient-perceived improvement & a minimum clinically important difference (MCID) of 5 points.

Question 23

Hurwitz study - Evidence for Manual Therapy in notes pt 352

When comparing Manipulation or mobilization with or without heat or estim - what were the findings?

Answer 23

Hurwitz found that “there may be no difference between manipulation and mobilization of the cervical spine for patients with neck pain”.

Question 24

What are the factors used to predict success with thoracic manipulation? How many are needed for success?

Answer 24

3 or more present=86% success with manipulation

1) Recent onset (< 30
6) Flat T3-T5

Question 25

What are the factors used to predict success with cervical manipulation? How many are needed for success?

Answer 25

3 or more present=90% success with manipulation

1) Recent onset (10 degree difference in rotation
4) Pain with spring (PA) testing middle cervical spine

Question 26

CPR for traction intervention success:

Answer 26

3 of 5: 79.2%

1) Positive neck distraction test
2) Age >55
3) + Shoulder abduction test
4) Positive UNLT 1/ULTTA A (median nerve) test
5) Symptom peripheralization with mobility testing of the lower cervical spine (C4-7)

Question 27

Ylinen et al. Active Neck Muscle Training in the Treatment of Chronic Neck Pain in Women (pg 361-2))

• Inclusion criteria
• Intervention
• Results

Answer 27

Inclusion criteria

1) Female office workers with neck pain
2) Age 25-53
3) Duration of symptoms >6 mos

Intervention (all pts received 5 group sessions/week for 4 weeks) Three Groups:

1) Endurance training - supine head lifts; shoulder/UE; trunk/leg training; stretching; aerobic
2) Strength training - theraband neck flexor exercises (forward/oblique/backward; 80% of isometric strength); shoulder/UE; trunk/leg training; stretching; aerobic
3) control group - stretching; aerobic

Results

• Strength group had greatest reduction in pain followed by endurance
• Minimal improvement for control group

Question 28

What is GROC?

Answer 28

GROC=Global rating of change & is used by many studies to define "success" in an intervention. The cut-off for "success" is different per study.
How much better are your symptoms? Are they:
\+7 A very great deal better
\+6 A great deal better
\+5 Quite a bit better
\+4 Moderately better
\+3 Somewhat better
\+2 A little bit better
\+1 A tiny bit better
0 About the same
-1 A tiny bit worse
-2 A little bit worse
-3 Somewhat worse
-4 Moderately worse
-5 Quite a bit worse
-6 A great deal worse
-7 A very great deal worse

Question 29

Jull article (11/12 reading; page 364 in notes)
Evidence for treatment of cervicogenic headache

Inclusion/Exclusion criteria
Interventions
Results

Answer 29

Inclusion/Exclusion criteria:

1) Unilateral HA provoked by neck movement or posture and tenderness in upper cervical spine
2) Age 18-60
3) excluded migraine h/a, workers comp patients

Interventions (4 groups) *8-12 sessions over 6 wks
—1) Manual therapy
— - Low velocity and high velocity mobilization/ manipulation to specific cervical spine mobility
restrictions; 30 Minute treatments
2) Manual Therapy and Therapeutic Exercise
—- 30 minutes of combined treatment
——3) Therapeutic Exercise
— - Low Load endurance activities to train cervicoscapular muscles
— a) Craniocervical flexion exercises longus capitus & colli in supine
— b) Serratus anterior & lower trap exercise in supine
— c) HEP-2 times daily
— - Postural Education
— a) Sitting with Neutral Spine
— b) Retraction and adduction of scapular spine
— c) Elongation of cervical spine with longus colli activation
— d) Throughout day
4) Control - No Interventions

Results
- Decrease in pain scores for all groups
- Decrease in # of HA/week and length of HA duration (biggest improvement for MT and exercise group)
- Significant improvement in craniocervical flexion
test for the the two groups receiving exercise

Additionally, this study showed improvement for all groups and is described in the number needed to treat. These numbers are important for referral sources.

Question 30

Post-Whiplash study by Rosenfeld (notes pg 367)
Inclusion/Exclusion criteria
Interventions
Results

Answer 30

Inclusion/Exclusion criteria

1) Within 96 hours of MVA
2) r/o fracture, dislocation, etc.

Interventions: 4 groups

1) Early Active: Treatment began within 96 hours; Gentle active ROM 10x every waking hour
2) Delayed Active: Treatment began after 14 days; Gentle active ROM 10x every waking hour
3) Early Standard: Advice on collar, active ROM; Advice on collar, active ROM
4) Delayed Standard:Treatment began after 14 days; Advice on collar, active ROM

Results
Early active had largest decrease in pain

Question 31

Post-Whiplash study by McKinney (notes pg 367)
Inclusion/Exclusion criteria
Interventions
Results

Answer 31

Inclusion/Exclusion criteria

1) Reported to ER within 48 hours of MVA
2) No pre-existing neck pain

Interventions

1) physiotherapy (manipulation)
2) rest
3) Early mobilization (advice to stay active, gentle ROM exercises)

Results: Indiv still experiencing symptoms after 2 years
– 46% physiotherapy (Worst outcomes)
– 44% rest
– 23% Early mobilization (Best outcomes)