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University of Delaware Cervical-Throacic Evaluation and Treatment Development of a Clinical Prediction Rule Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks.

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Presentation on theme: "University of Delaware Cervical-Throacic Evaluation and Treatment Development of a Clinical Prediction Rule Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks."— Presentation transcript:

1 University of Delaware Cervical-Throacic Evaluation and Treatment Development of a Clinical Prediction Rule Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks PT, PhD

2 University of Delaware Special Tests n Debate in the meaningfulness and usefulness of Vertebral Artery Testing n ? Interpretation of a negative test n If positive, further evaluation is indicated

3 University of Delaware Vertebral Artery Test n Combined Movements to stress test the cervical spine n Symptoms: –Dizziness -Tinnitus –Lightheadedness –Nystagmus -Parathesia –Dysarthria - Diplopia –Dysphagia

4 University of Delaware Vertebral Artery Preliminary Test n Patient is sitting. Sustain cervical extension for 10 seconds. n Sustain Rotation (L and R) 10 seconds n IF POSITIVE STOP n If the testing is negative progress to standard position.

5 University of Delaware Vertebral Artery Standard Test n Patient is supine. Sustain cervical extension for 10 seconds. n Sustain Rotation (L and R) for 10 seconds n Combine Extension with Rotation (L and R) for 10 seconds. n Test the patient in the manipulation position n IF POSITIVE STOP, do not manipulate

6 University of Delaware Cervical Distraction n Nerve Root Compression n Radicular pain is decreased, test is positive

7 University of Delaware Cervical Compression Test n Pressure downward on head n Test is positive if pain is evoked

8 University of Delaware Spurling A n Seated n Neck Side bent to the ipisilateral side n 7kg of overpressure applied n Presence of pain, parasthesial or numbness

9 University of Delaware Spurling B n Seated n Extension n Sidebending and Rotation to the ipsilateral side n 7kg of axial pressure is applied

10 University of Delaware Sharp –Purser Test n Neck in semi flexion n Palm of one hand on forehead n Index finger on Spinous process C2 n Posterior force through forehead n Posterior slide is + for AA instability

11 University of Delaware Shoulder Abduction Sign n Most common nerve root compression at C5-6 n Decrease in symptoms is positive response

12 University of Delaware Median Nerve Testing n Shoulder Retraction and Depression n Shoulder Extension n External Rotation n Elbow Extension n Forearm Supination n Wrist/Finger Extension n Cervical SB and Rot Away

13 University of Delaware Upper Limb Tension Testing A n Scapular Depression n Shoulder Abduction n Shoulder ER n Elbow Extension n Forearm Sup n Wrist and Finger Extension

14 University of Delaware Radial Nerve Testing n Proximal as for Median n Shoulder Internal Rot n Forearm Pronation n Wrist Flexion n Ulnar Deviation n Finger Flexion

15 University of Delaware Upper Limb Tension Testing B n Supine in 30º Abd n Scap Depression n Shoulder IR n Elbow Extension n Wrist and Finger Flexion n Opposite Cervical SB and Rot

16 University of Delaware Ulnar Nerve Testing n Shoulder Retraction n Shld Ext and ER n Elbow Flexion n Forearm Supination n Wrist Extension and Radial Deviation n Finger Extension n Cervical SB and Rot away

17 University of Delaware T1 Nerve Root Stretch n Abduct to 90º n Flex pronated arms to 90º n Flex elbows and place behind the neck n Pain in scapular area is T1- Pain in Ulnar distribution is Ulnar

18 University of Delaware Thoracic Outlet n Roos Test –Standing Abduct arm to 90° –ER shoulder –Open and Close hand for 3 minutes n Positive if unable to maintain position or heaviness/tingling in arm

19 University of Delaware Thoracic Outlet n Adson Maneuver n Supine n Palpate Radial Pulse n Abduct, Extend and ER arm n Take deep breath and rotate toward arm n + Subclavian if change in radial pulse

20 University of Delaware Thoracic Outlet n Halstead Maneuver n Palpate radial pulse and distract UE n Patient extends and rotates cervical spine to opposite side n Positive for TOS if absence of pluse

21 University of Delaware Cervical Evaluation Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks PT, PhD

22 University of Delaware Determining Severity n Stage 1 –Inability to perform basic mechanical functions »Stand for 15 minutes »Sit for 15 minutes »Walk greater than ¼ mile –Cervical Oswestry (NDI) ≥ 30% »Often as high as 50% (less than 2 wks otherwise r/o symptom magnification) –Tx- Pain modulation and movement

23 University of Delaware Stage 1 Treatment n Joint Manipulation\Mobilization n Traction n Active Spinal Movement n Sleeping Postures n NSAIDS n Physical Agents n Cervical Collar (rest from function only)

24 University of Delaware Determining Severity n Stage II –Unable to carry out ADL’s »Vacuum, lift, push, pull – Oswestry (NDI) 20-30% n Treatment –Weakness –Tightness –Posture –Body Mechanics –Active Exercise

25 University of Delaware Determining Severity n Stage III –Can perform ADL’s and high demand for brief time periods –Cannot return fully to high demand activities »Sports, occupational duties, deconditioned –Cervical Oswestry(NDI) ≤ 20% n Treatment- Return to work/play –Ergonomic Assessment/Modifications –Endurance

26 University of Delaware Assessment of Movement n Cyriax Capsular Pattern –Full flexion, limited extension and symmetrically limited rotation and sidebending –Arthritis, inflammation or DJD of the joints –Flexion is not significantly involved since the neck tolerates flexion well –Restricted flexion »Upper Thoracic and Cervicothoracic junction

27 University of Delaware Range of Motion n Flexion n Extension n Sidebending n Rotation –Note quantity –Quality (deviations/location) –Symptom provocation –Active and Passive overpressure n Clear the shoulder (pain free ROM)

28 University of Delaware Non capsular pattern n Flexion is limited (non capsular) –Often cervicothoracic or upper thoracic jxn n Opening Restrictions n Closing Restrictions n Combination Restrictions –Significant dysfunction –Located 2 or more areas –Compensations

29 University of Delaware Referred Symptoms n Closing Restriction –Extension and Sidebending reproduce sx’s n Limited Cervical Flexion and symptoms –Not typical decreased cervical flexion with symptoms in upper back n Sidebending to opposite side produces distal symptoms

30 University of Delaware Upper Quarter Screen n Spurling’s n Hoffman’s Reflex (Babinski of UE) n L’hermittes n Reflexes n MMT n Sensory Testing

31 University of Delaware Consider Disc n True limitation in cervical flexion n Radiculopathy recreated with motion n Neurological findings –Refer for MRI

32 University of Delaware Cervical Evaluation n Passive Range of Motion with endfeel n Joint Play –Central PA glides –Prone unilateral PA’s (facet glides) –Supine downglides –Can perform in Neutral, Flexion and Extension

33 University of Delaware

34 Response to Range of Motion Capsular Pattern (No Radiculopathy)? Stage I Mobs, Traction, Modalities, NSAIDS, Sleeping PosturesStage I Mobs, Traction, Modalities, NSAIDS, Sleeping Postures Stage II Active Exercise, Postural Correction, Daily ActivitiesStage II Active Exercise, Postural Correction, Daily Activities Stage III Ergonomic Assessment and ModificationsStage III Ergonomic Assessment and Modifications Yes Determine Stage and Treat

35 University of Delaware Response to ROM No Capsular Pattern Is Flexion Limited? Yes No Assess and Tx C-T and T jxn Is there an opening Restriction? Yes Joint Mobs for opening No Is there a Closing Restriction? Yes Joint Mobs for closing No Likely a combined lesion

36 University of Delaware Limited Forward Flexion Traction Manip to C-T Junction and Thoracic Full Passive Flexion (see next) Forward Flexion Still Limited Try Cervical Traction No Change: MRI for mechanical block Improve:Continue

37 University of Delaware Full Flexion Opening Restriction No Radicular SXs during movement Opening Manipulation Radicular SXs during movement +TOS signs Joint Mobs for opening -TOS signs Traction Manipulation +Radicular SXs on Opening ICT -Radicular SXs on Opening Opening Manipulation

38 University of Delaware Upper Thoracic Manipulation n CT junction n Patient sits far back on table n Stabilize shoulders n Use their hands as fulcrum n Distract upwards –Drop down

39 University of Delaware Thoracic Outlet n Clavicle, 1 st Rib and Costoclavicular lig, subclavius and ant scalene n Compression of subclavian or axiallary artery, vein, or brachial plexius (C8 and T1) n Costoclavicular syndrome –Loss space between clavicle and 1 st rib n Cervical Rib (<1%) syndrome –Cervical rib from C7 or band of fibrous tissue in area

40 University of Delaware Thoracic Outlet n Anterior Scalene Syndrome –Compression of neurovascular bundle between anterior and middle scales –Tingling 4 th and 5 th digit –Ulnar and Median weakness –If vascular hand edema n Testing should recreate symptoms n Vascular change alone is not predictive n Exacerbated by shoulder hypermobility –Dead arm

41 University of Delaware Full Flexion and Closing Restriction No Radicular Symptoms on closing Closing Manipulation

42 University of Delaware Full Flexion and Closing Restriction Traction Manip Radicular symptoms on closing + Neuro Signs + Radicular with Closing -Radicular with Closing ICTClosing Manip - Neuro Signs Opening Manip + Radicular with Closing - Radicular with Closing Traction ManipClosing Manip

43 University of Delaware Early Treatment for Pain n 3 Finger Treatments- Painfree ROM –Neck Retraction –Lateral Flexion –Rotation n Decrease flexion (increase fingers) as pain subsides

44 University of Delaware Early Treatment for Pain n Rest –Throughout day, interrupt activity n Supported Sleep –Butterfly pillow (good cervical pillow) n Upright Posture –Avoid hanging head –Collar As Needed

45 University of Delaware Stage II Treatment n Improve Range –Joints, muscles, neural tissue n Improve Stability –Strengthen weak muscles –Improved Postural Control n Improve Aerobic Capacity –Activity endurance

46 University of Delaware Self Stretching/Joint Mobs n Use hands to stabilize cervical spine n SNAG’s with towel

47 University of Delaware

48 Indication for Cervical Manipulation n Most successful in presence of a specific restriction (primarily mechanical block) n TTenderness n A Asymmetry n R Restriction of Movement n T Tension (muscle and soft tissue) Bourdillon 1970

49 University of Delaware Differential Diagnosis n History –Fracture or Instability –Index of Suspicion Intoxication, LOC, High Energy Injuries –x-rays lateral(flex/ext),AP,open mouth,obliques –Osteophytic Encroachment –Whiplash(acceleration injury)

50 University of Delaware Contraindications to Manipulation n Paget’s Disease n Rheumatoid Arthritis n Osetomyelitis n Ankylosing Spondylitis n Malignancy n Cord and Cauda Equina Syndrome n Vertebral Artery Involvement

51 University of Delaware Complications Due to Manipulation Neurovascular Complications Neurovascular Complications AuthorCases AuthorCases n Sherman, Smialek &Zane 52 n Grant 58 n Patijin 84 n Terrett 107 n Kunnasmaa & Thiel 139 (Rivett, Milburn 1996)

52 University of Delaware Lee et al. Neurology 1995 n Survey of 177 Neurologists n Report of neurologic complications following chiropractic manipulation n 102 Complications 56 Strokes 13 Myelopathies 22 Radiculopathies

53 University of Delaware n Hurtwitz et al Spine n Complication Rate –5-10 in 5 to 10 million –Less than 120 cases in English »Primarily Vertebrobasilar accident (VBA) n Brain stem or cerebellar infarct »Cord compression, Fracture, Tracheal rupture »Diaphragm paralysis, carotid hematoma or cardiac arrest

54 University of Delaware Injury on 118 Complications n Initial Complaints n 37 (31.5%) Neck Pain n 10 (8.5%) Neck stiffness n 17 (14.5%) Head and neck pain or stiffness n 23 (19.5%) Headaches n 31 (26%) Other –Torticollis, back pain, head colds

55 University of Delaware Injury in Manipulation n 82% were rotational manipulations n 66% had signs or symptoms of VBA –After first manipulation n 78% had consequences of VB ischemia –20 died –42 had residual symptoms n Risk for Mild complication 1 in 40,000 n Risk for Serious complication 1 in 1 million

56 University of Delaware Complications Resulting from Treatments of the C-spine Treatment Complication n ManipulationVBA, Major Complication or Death –5-10/10,000,000 n Cervical Surgery –15.6/1000Neurological Compromise –6.9/1000Death n NSAIDSSerious GI event 3.2/1000 (age 65+)Bleeding, perforation, or other.39/1000 (<65) resulting in hospitalization or death 3.2/1000 (age 65+)Bleeding, perforation, or other.39/1000 (<65) resulting in hospitalization or death 1/1000 (Ages combined) 1/1000 (Ages combined)

57 University of Delaware Examination n Perform an Upper Quarter Screen –Check dermatomes –Check myotomes –Check reflexes

58 University of Delaware Range of Motion n Cervical spine facet motion –Flexion causes facet opening –Extension causes facet closing –Rotation and Lateral Flexion(SB) occur in the same direction –Rotation and Lateral Flexion cause facet opening contralerally and closing ipsilaterally

59 University of Delaware Cervical Facet Opening/Closing n Maximal Left Opening –Forward Flexion –Right Rotation – Right Sidebending n Maximal Left Closing –Extension –Left Rotation –Left Sidebending

60 University of Delaware Treatment/Manipulation n To Open or Close? –Force a stuck drawer close –Open the drawer fully and then attempt to close it

61 University of Delaware Cervical Manipulation Procedure n Position patient comfortably n Palpate the cervical treatment level n Flex or Extend the neck until tension/approximation is noted at the spinal interspace above the desired level n Rotate the head to end range n During patient exhalation - stress end range n Quickly overpress when the patient relaxes n Reassess the patient’s movement and record

62 University of Delaware Manipulation Position for Right Cervical Closing

63 University of Delaware Alternative to Manipulation n Follow the outlined treatment(no overpress) –Oscillate the head at end range n Traction (manual or mechanical) n Soft tissue Treatment –Modalities –Massage n Seek training with skilled manipulator n Refer patient to skilled manipulator

64 University of Delaware Myth of Manipulation n Manipulation is not –Dealing with dislocation/subluxation –Correcting a “little bone out of place” –Restoring a “slipped disc” n Manipulation is –Designed to overcome a motion restriction

65 University of Delaware Cervical Radiculopathy

66 University of Delaware Cervical Case

67 University of Delaware Reliability and Accuracy of Clinical Exam for Cervical Radiculopathy n Wainner Spine 2003 n 82 Patients with suspected Cervical radiculopathy or carpel tunnel n Electrophysiological Testing –Nerve Conduction Study –Needle Electromyography n Clinical Exam –34 items and 2 raters

68 University of Delaware Wainner Spine 2003 n Data Collected –Visual Analog Scale –NDI –History Questions –MMT of Upper Quarter –Reflexes –Pin prick sensation –Cervical ROM »2 warm up- 1 trial with inclinometer

69 University of Delaware Provocative Tests n Induce or alleviate mechanical pressure n Enlarge neural foramen n Stretch or slacken neural elements n Increase intrathecal pressure

70 University of Delaware Wainner Spine 2003 n Provocative Testing –Spurling A –Spurling B –Shoulder Abduction Test –Valsalva Maneuver –Neck Distraction –Upper Limb Tension A and B

71 University of Delaware Cervical Radiculopathy n Upper Limb Tension Test A (symptoms recreated, ≥10° elbow ext. difference or wrist flexion, cervical SB’ing increases sx.) n Involved Cervical Rotation less than 60 degrees n Distraction Test (Supine examiner distracts- symptoms reduced) n Spurling A (Sidebend with compression)

72 University of Delaware Cervical Radiculopathy n Upper Limb Tension Test A n Involved Cervical Rotation of less than 60° n Distraction Test (Reduces symptoms) n Spurling A – ( if negative best to rule out) n 2 Tests = 21%3 tests= 65% n 4 Tests= 90% Reference Criterion- Electrophysiological Testing

73 University of Delaware Radiculopathy Treatment n Cleland JOSPT 2005 n Diagnosis based on Wainner et al. n Case Series of 10 patients n 6 month Follow up

74 University of Delaware Subjects n 11 of 28 satisfied criteria n Age =  51.7 (S.D. 8.2) n Symptom Duration=  18 weeks (8-52) n Treatments =  7.1 (6-10) n 9 of 11 had neck & upper extremity pain (82%)

75 University of Delaware Treatment n Cervical and Thoracic Mobilizations n Deep neck flexor –Supine flattening cervical lordosis with nod –10 second hold/ 10 reps n Scapular exercises –Middle and Lower trap (prone on plinth) –Serratus Wall push ups n Mechanical traction to centralize or reduce sx’s –Intermittent 30:10 for 15 minutes –8.2 kg (18lbs) increased.5-1kg/visit

76 University of Delaware Cervical Lateral Glides

77 University of Delaware Thoracic Manipulations

78 University of Delaware Outcomes n Discharge: 8 of 11 (73%) were negative on cluster of tests –2 had positive Spurling’s but improved function –1 had ULTT and Suprling’s n 10 Patients (91%) had clinically meaningful reductions in pain and disability –(> 2-7pt change) –Lasted for 6 months- »45 % had 10/10 »50% had mild limitations

79 University of Delaware Expand Criteria n If treatment aimed at thoracic helps with radiculopathy- how about neck pain?

80 University of Delaware Subjects n Primary Complaint of Mechanical Neck Pain –Nonspecific pain in cervicothoracic jxn worsened with neck movements n NDI n VAS (0-100) n 36 subjects

81 University of Delaware Randomized Treatment n Thoracic manipulation n Sham Manipulation

82 University of Delaware Immediate Response to Manipulation

83 University of Delaware Clinical Prediction Rule n Which patients with neck pain can benefit from thoracic manipulation, exercise, and patient education? n Cleland et al. Physical Therapy 2007

84 University of Delaware Clinical Prediction Rule for Neck Pain n n Age n n Neck pain with and without unilateral arm symptoms n 10% n NDI > 10% n Exclusions: Red flags, whiplash < 6 weeks, cervical spinal stenosis, CNS problem –2 signs of nerve root myotomes, sensation, reflexes n Numeric Pain Rating n NDI and FABQ n Distal symptom local n Various measurements –Neurological Screen –Postural assessment –Cervical ROM –Joint Mobility –Strength/endurance of muscles –Spurlings, Roos, Distraction, ULTT

85 University of Delaware

86 Intervention n 3 Thrust Manipulations –2 reps of each n Seated Distraction

87 University of Delaware Intervention n Supine Upper Thoracic Manip

88 University of Delaware Intervention n Supine Middle Thoracic Manipulation

89 University of Delaware Other Intervention n Cervical ROM

90 University of Delaware Outcomes n Greater than +5 point change on global rating of change n If not achieved after treatment 1, repeated on next treatment n No +5 after 2 treatments= Non Responder

91 University of Delaware


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