Treatment of the Cervical Spine

Question 1

Que técnicas de terapia manual podem ser utilizadas na cervical?

Answer 1

Manobra de deslizamento do tecido conectivo;
Mobilização das vértebras cervicais;
Manobra do trapézio superior, esplênio, escalenos, esterno-cleido-mastoideu e elevador da escápula;
Mobilização da coluna cervical.

Question 2

Qual o princípio na realização das manobras do trapézio superior, esplênio, escalenos, esterno-cleido-mastoideu e elevador da escápula?

Answer 2

O fisioterapeuta posiciona-se à cabeceira da marquesa com uma mão apoiada na origem do músculo, realizando um leve tensionamento dos tecidos miofaciais, e com a outra mão realiza estiramento em direção ao sentido oposto.
Pode realizar-se a manobra durante 3 expirações, 3 vezes de cada lado.

Question 3

Como se realiza mobilização das vértebras cervicais?

Answer 3

O fisioterapeuta posiciona-se à cabeceira da marquesa com as duas mãos sob a coluna cervical, com os dedos indicadores, médio anular e mínimo apoiados nos processos transversos das vértebras realizando movimentos de dissociação das vértebras no sentido lateral, realizando com freqüência de 4 a 5 vezes.

Question 4

Como mobilizar o tecido conectivo da cervical?

Answer 4

O fisioterapeuta posiciona-se à cabeceira da marquesa, com as duas mãos sob a região cervical deslizando os dedos indicador, médio, anular e mínimo da região caudal para occipital, com leve pressão e de forma lenta com freqüência de 4 a 5 vezes.

Question 5

Explica uma abordagem a trigger points cervicais.

Answer 5

O indivíduo senta-se numa cadeira, com a região cervical e torácica desnuda, de costas para o fisioterapeuta. Este aplica uma pressão om o dedo polegar, de acordo com o limite de dor relatado pela pessoa. Esta técnica pode ser realizada 2 a 3 vezes em cada ponto gatilho, até cessar a dor referida. Geralmente aplica-se sobre a região do extensores do pescoço, trapézio, elevador da escápula e rombóides.

Question 6

Qual a relação entre os trigger points e os problemas articulares?

Answer 6

There is scientific evidence showing change in muscle sensitivity in muscle TrP after spinal manipulation, which suggests that clinicians should include treatment of joint hypomobility in the management of TrPs. Nevertheless, the order in which these muscle and joint impairments should be treated is not known and requires further investigation.

Question 7

Que tipo de exercício que parece ter melhores resultados?

Answer 7

Endurance over strengthening; Include thoracic and shoulder musculature too.

Question 8

Que tipos de tratamento parecem resultar na coluna cervical?

Answer 8

Exercises;
Manual Therapy (Manipulation and Mobilization);
Multi-modal (exercise + MT) - Este último parece demonstrar efeitos maiores.

Question 9

Quais são as cinco treatment-based classifications for neck pain?

Answer 9

• Pain Control - Stabilize and Palliative;
• Mobility - Mobilization or Manipulation;
• Exercise and Conditioning (nonmobilization);
• Headache - Mobilization and Postural Treatment;
• Centralization - Traction Group.

Question 10

Que implicações estão associadas à pain control classification?

Answer 10

• Whiplash Associated Disorder
• Severe pain from sprain and strain

• Treatments include modalities, general strengthening exercises, and general manual therapy procedures.

Question 11

Que condições podem estar associadas à mobility classification?

Answer 11

• Herniated disk
• Spondylosis
• Neck Strain/Sprain
• (occasionally) Whiplash Associated disorder

• Treatments would be active movement, Home Exercise Program, Combined, Mobilization and Manipulation.

Question 12

Quais as condições dirigidas para a Exercise and Conditioning classification?

Answer 12

• Spondylosis
• Whiplash Associated Disorder
• Neck Strain/Sprain
• Headache (Tension)
• Postural

• Treatments will include general conditioning exercises and stretching.

Question 13

Que condições podem ser inseridas na headache classification?

Answer 13

• Cervicogenic Headache
• Tension Type Headache

• Treatments will include focused strengthening exercises and mobilization/manipulation. Also massage/stretching.

Question 14

Quais as condições mais prevalentemente relacionadas com a centralization classification?

Answer 14

• Herniated disk
• Stenosis
• Spondylosis
• Postural syndrome

• Treatments will include selected manual techniques, traction, and positional based active and passive exercises.

Question 15

Quais os tratamentos demonstram mais eficácia no tratamento da dor cervical?

Answer 15

Exercise, mobilization, and manipulation have the best evidence in the literature.
Little evidence for use of TENS, ultrasound, thermal agents, and electrical agents (other than transient effect).

Se usarmos exclusivamente modalidades para o tratamento da cervical, estamos a perder o foco do problema. Porém, estas podem ser utilizadas como “ponte” para técnicas que tendem a apresentar melhor efeito.

Question 16

O que parece apresentar melhor evidência em Acute Whiplash Disorders?

Answer 16

Light mobilizations demonstrate the most evidence in treatment of acute whiplash.
Limited evidence for manipulations.
Transient evidence for modalities (TENS, ultrasound, etc.).

Question 17

Como se aplica passive chin retraction? E em que pode ajudar?

Answer 17

• Passively retract the chin of the patient
• Stabilize the head posteriorly
• Slowly, bring the head into extension
during passive movements
• Keep the chin retraction

Pode ajudar em indivíduos com anteriorização da cabeça (porém pode ser desconfortável, temos que ir trabalhando lentamente).

Question 18

Como instruir Anterior Neck Flexion Exercises? E em que podem ajudar?

Answer 18

The treatment is performed in a supine position. The patient is instructed to perform upper cervical flexion with a blood pressure cuff placed posteriorly in the back of the neck. They are instructed to hold for 10 seconds at least 10 times. Se tiver houver cuff para orientar, não deve ultrapassar uma força de 10 mmHg.

Analgesic in nature, Low Load retraining is needed; Show short term effectiveness.

Question 19

Qual a evidência disponível acerca da mobilização e manipulação?

Answer 19

“Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.”

Question 20

Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain?

Answer 20

“Manipulation was more effective than medication in both the short and long term. However, a few instructional sessions of HEA resulted in similar outcomes at most time points.” So, manipulation and a Robust Home Exercise Program were better than medications for mechanical neck pain (Very nicely designed trial, 52 week follow up).

Ann Intern Med. 2012;156:1-10

Question 21

Manual therapy vs. exercise for neck pain?

Answer 21

Moderate quality evidence supports treatment combination of manual therapy and exercise for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash.

Miller et al. Manual therapy and exercise for neck pain: A systematic review. Man Ther. 2010 Jun 1.

Question 22

In the centralization group, nós devemos prestar atenção à possibilidade de radiculopatia cervical. Qual é a clinical prediction rule?

Answer 22

• Positive ULTT test
• Less than 60 degrees of cervical rotation
• Positive Spurling’s Test
• Positive Distraction Test

2 of 4 positive is a LR+ of 0.80
3 of 4 positive is a LR+ of 6.1
4 of 4 positive is a LR+ of 30.3

Question 23

Há benefício através da tração cervical?

Answer 23

Intermittent better than continuous (for pain reduction) - only one quality study;
Actually demonstrated more benefit for mechanical neck pain that cervical radiculopathy.
Halter traction and neck brace may be helpful (caution cohort study).

Question 24

Qual a clinical prediction rule to the use of mechanical traction?

Answer 24

(1) patient reported peripheralization with lower cervical spine (C4-7) mobility testing; (2) positive shoulder abduction test; (3) age > or =55; (4) positive upper limb tension test A; and (5) positive neck distraction test.

3 of 5 predictors was +LR equal to 4.81 (95% CI = 2.17-11.4), increasing the likelihood of success with cervical traction from 44 to 79.2%.
4 of 5 variables, the +LR was equal to 23.1 (2.5- 227.9), increasing the post-test probability of having improvement with cervical traction to 94.8%.

Question 25

Quais as variáveis identificadas para a utilização de home traction units?

Answer 25

Fear-Avoidance Beliefs Work Subscale score inferior 13; pre-intervention pain intensity superior or equal to 7/10; positive cervical distraction test; and pain below shoulder.

With satisfaction of at least three out of four variables, the intervention’s success rate increased from 45.6% to over 80%.

Question 26

How to perform an opening thrust manipulation?

Answer 26

The patient is placed in a position of flexion, side flexion and rotation away. The thrust manipulation used is a slight rotation, lateral break movement.

Esta técnica poderá ajudar quando a pessoa sente dor na flexão do pescoço ou inclinação lateral ou rotação na direção oposta à área dolorosa. Quando “abrem a faceta” sentem dor, e o thrust irá causar essa abertura.

Question 27

Como aplicar um closing thrust manipulation?

Answer 27

The patient is placed in a position of extension, side flexion and rotation away. The thrust manipulation used is a lateral break technique, driven toward the opposite hip as the side treated.

Question 28

How we perform the C0-1, C1-2, and C2-3 mobilization?

Answer 28

The C0-1 position is in prone with pressure placed on the lateral aspect of C1 downward toward the ispilateral eye.

C2-3 and tested in the same manner as a C2-3 UPA - mobilize the C2-3 facet pushing downward vertically toward the table.

In C1-2 the thumb remains on the C2-3 process, turn the head 30 degrees to the same side, and mobilize toward the patient’s mouth.

Question 29

When we execute a manual traction technique?

Answer 29

The treatment is performed in supine. The distraction is used to see if symptoms abate during the distraction process.

Question 30

How its done a Thoracic Pistol Manipulation? E qual a evidência no que diz respeito à manipulação torácica superior para aliviar a dor na cervical?

Answer 30

The patient is held in a flexed position and the clinician provides a blocking force below the region of the targeted manipulation. The flexed position is held throughout the procedure.

Thoracic manipulation has a better response than eletrical stimulation, infrared, mobilization to the thoracic spine, and exercises, but is not better than treatment directed specifically to the neck.
Disabil Rehabil. 2013 Jan 23.

Question 31

Existe alguma indicação específica para Cervical Stretching? E há evidência que suporte a sua aplicação?

Answer 31

We should stretch our patients, specially those who have abnormal tightness in upper trapezius in headache and postural patients.

Low to moderate quality evidence supports the use of specific cervical and scapular stretching for neck pain post treatment and intermediate term and for headache patients in the long term.
Disabil Rehabil. 2013 Jan 23

Question 32

How to do a general thrust manipulation?

Answer 32

A técnica é semelhante à closing and opening technique, porém the neck is held in neutral. So the technique used involves side flexion and rotation away. The thrust procedure is a lateral break movement (e trata o lado oposto ao movimento).

Question 33

Como fazer passive thoracic stretching?

Answer 33

Using a belt, the patient is strapped snuggly to the table just below the restricted region. The patient then clasps their fingers together and places each on their forehead. The clinician then provides an extension force to the patient letting the belt assist in the stretch.

Question 34

Qual a importância da educação do paciente?

Answer 34

Ao contrário da low back pain (em que aconselhar manter-se ativo é uma das melhores intervenções), educational interventions for cervical pain alone has not shown effectiveness - including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies. Future research should be founded on sound adult learning theory and learning skill acquisition.

Question 35

Que tipo de exercícios devem ser recomendados num home-based plan? Quantas vezes estes devem ser realizados?

Answer 35

Alongamentos, mobilizações, retrações do queixo, and subtle endurance related streghtening exercices.

Devem ser realizados 6 to 8 times daily.

Question 36

Além da cervical, que zonas podemos adereçar como intervenção adjuntiva? E existe evidência para a sua utilização?

Answer 36

Upper Quadrant and Parascapular Strengthening.

Low to moderate quality evidence to show that upper extremity stretching and strengthening does not have enough utility to be used exclusively.

Question 37

Existem outras abordagens alternativas para a dor cervical?

Answer 37

Yoga was more effective in relieving chronic nonspecific neck pain than a home-based manual for self care.
Aerobics? We don’t know.
Other alternative approaches? We also don’t know.