W5: Workshop Flashcards
- Emily is a dentist reporting neck pain and headache. She is unable to tolerate working for long hours when performing dental surgery (leaning over patients). She starts each day with no pain, however after 30 minutes of working she starts to get pain behind her eye and in her neck. She also reports significant neck stiffness and pain. On observation you note that she has considerable forward neck posture.
- On assessment you not that she has reduced rotation ROM (left) during the flexion rotation test – 50% compared to right, and is tender on PAIVM assessment {central and unilateral at C2 (6/10 NRS)]
Cervicogenic headache
Indicators:
- Neck Stiffness and pain
-
Prior to assessing deep cranio-cervical flexors what must be done?
Assess for neural tissue mechanosensitivity - first assess passive range, then put them in a sensitising position.
Afterwords you can proceed on with using the biofeedback unit (inflat to 20mmhG, etc)
What is a cervicogenic headache?
Cervicogenic headache: describes headache caused by abnormalities of the joints, muscles, fascia and neural structures of the cervical region. Structures innervated by C1-3 can refer pain to the head.
When would you use a cervical traction?
- Generalised mvmt restriction (e.g. degenerative changes), particularly for irritable conditions, acute rye neck
What does mulligans invovle?
Involves performing a sustained force (accessory glide) while a previously painful (problematic) movement is performed.
The MWM is indicated if, during application, the technique enables the impaired joint to move more freely without pain. The technique must be pain free.
In comparison to Maitland (above), Mulligan does not prescribe grades of movement or oscillatory movements (e.g. mobilisations).
NAG vs SNAG. When are SNAG’s used?
- NAG: natural apophyseal accessory glides applied to the c/sp or th/sp. These techniques are passive techniques (patient does nothing)
- SNAG: sustained natural apophyseal accessory Glides - patient actively moves joint through ROM whilst the therapist performs an accessory glide parallel to Rx plane.
SNAGS are very common for lumbar spine (this was the only workshop we used them in eg side bending snag, snag in sitting, extension self snag w/belt, flexion self-SNAG w or without belt
What are Maitland’s grades?
Maitland grades:
* Grade 1 = a small amplitude movement near the starting point of R1 but not into resistance
* Grade 2 = a large amplitude movement near the starting point of resistance which is free of stiffness or spasm
* Grade 3 = a large amplitude movement that moves into stiffness or spasm
* Grade 4 = a small amplitude movement that moves into stiffness or spasm.
When would you use a central PA?
- Central PA to spinous process typically of most benefit to patients with either midline symptoms or symptoms distributed evenly to each side of the head, neck, arms or upper trunk
When would you use a unilateral PA?
- Unilateral PA mobilisations are used for unilateral symptoms on the side of the pain. Often performed on the facets to improve rotation ROM
When would you use a transverse mobilisation?
- Used for unilateral symptoms. Particu¬larly if the Sx do not extend far from the vertebrae, when no neurological signs are evident.
- Tip: when this technique is used for treating pain that is felt unilaterally, it is more likely to produce an improve¬ment if direction of the pressure is performed from the non-painful side towards the painful side.
- Lateral flexion in the typical cervical spine is ….. coupled: e.g. if joint restriction is causing reduced left lateral flexion – patient will also have reduced left rotation). That way lateral flexion PPIVMs can be used to treat ….. ROM deficits.
Ipsilateally
Rotation
How can lateral flexion PVIMMS be varied for irritable vs non-irritable patients?
Lateral flexion PPIVMs can be performed away from side of pain (irritable patient), or towards the side of reduced rotation/lateral flexion (non-irritable patient – where ROM increase is primary goal)
PVIMMS can also be used to open nerve root on one side, explain?
e.g. Left lower C6/7 nerve root pathology – perform right lateral flexions
Rotation MWM (C6-T4) - when would you use it?
- Reduced cervical rotation/pain with rotation
- Hypo-mobility cervico-thoracic region
When would you use the following soft tissue release:
- Trigger point ant scalene/upper traps
- STM of sub-occipitals
- Indication: muscular tightness causing limited ROM (e.g. lateral flexion/rotation)
- Indications: reduced CCF ROM (muscular restriction)
Common treatment techniques for cervicogenic headache?
Advice and education:
* Address provocative postures
* e.g. ergonomics, posture, bike set up, computer set up (e.g. lap top vs external monitor)
* Posture cues
Acute management: reduce pain and improve ROM
* PAIVM techniques to upper c/sp (as above)
* Stretches: localised upper cervical stretch (overpressure into upper cervical flexion with hand)
* STM to sub-occipitals if CCF is reduced (ROM) due to soft tissue restriction
Exercises:
* Address strength movement control as indicated [cervical flexors (e.g. DNF), cervical extensors, axio-scap musculature]
Physical criteria for cervicogenic headache?
Articular
✓ Decreased cervical ROM
✓ Upper cervical segmental joint dysfunction
Muscular
✓ Altered neuromuscular control
✓ Reduced strength and endurance
+/- Short muscles
Postural
+/- Forward head posture
Neural
+/- Neural tissue mechanosensitivity
True or false in cervicogenic headaches/cervical/head pain assessment of the axio-scapula musculature should occur?
True
- Patients tested against resistance of therapist (isometric). Scapular should remain fairly stable.
- Resisted abduction – expose inability to maintain upward rotation of scap
- Resisted flexion – expose inability to control posterior tilt of scap
- Resisted ER – expose inability to externally rotate scap
- Resisted abduction – exposure inability to maintain upward rotation of scap
Then assess in closed chain position
When assessing the scapula what are common inappropriate muscle actions?
Common inappropriate muscle actions include
- Dominance by the latissimus dorsi (arm and scapular depression)
- Dominance by rhomboids or levator scapulae (elevation of the scapular border and downward rotation
- Dominance by arm external rotators such as infraspinatus and teres minor (patient attempts to hold the position by raising the elbow and externally rotating the arm
