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MOD 8 : C-Spine

C-Spine Trauma, Pain, and Dysfunction

QuestionAnswer
What percentage of people will have Cspine neck pain in their lives? At any given time, what % has cspine pain? Estimated 22% to 70%. 10-20%
Prevalence of neck pain increases with what? age
Most common population to experience neck pain and dysfunction are?why? Most common in women around the fifth decade of life.-revert back to C curve-lose our lordotic curve-less fluid in jts, (djd)OA
History of neck pain is?However rates of ? are high favorable-most people get better.recurrence and chronicity
What % of population is disabled by neck pain? 5%
Neck pain patients make up what % of patients receiving outpt PT? 25%
What causes neck pain? Most do not have an identifiable pathoanatomic cause-Difficult to correlate diagnostic tests with symptoms.Most patients are classified as “mechanical neck disorders” (MND)-no visible pathology, but there is something wrong with the mechanics
PT should focus on ? for their neck pain pts PT should focus on impaired function of muscle, connective, and nerve tissues.
List 8 risk factors for Chronicity >40ys, coexisting LBP, long hx neck pain, cycling reg, decreased hand strength, worrisome, poor QOL, less vitality
Definition of Whiplash injury neck in car accident-usually get hit from behind. 1st whip into ext, then whip into flexion. If you hit them, reverse-sprain/strain-hyperflexion and hyperext
5 sequelae of whiplash trauma *R/O fracture, dislocation, subluxation*soft tissue injuries*neurologic injury*Dysphagia-hurts when u swallow*vertebral artery injury
Most whiplash injuries result in? minor c spine strains/sprains
What is the Canadian Cervical Spine Rule?(CCR) A highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients.
The CCR comprises 3 main questions. What is the first? Presence of high risk factors? (age 65 or older, dangerous mechanism, paresthesias in extremities) If yes, radiography indicated.
The CCR comprises 3 main questions. What is the second? Presence of low-risk factors that allows safe assessment of C-spine ROM:*Simple rear-end MVA*Sitting position in the emergency dept.*Ambulatory at any time since the injury*Delayed onset of neck pain*Absence of mid-line C-spine tenderness
The CCR comprises 3 main questions. What is the third? Can the patient actively rotate neck 45° to the left and right?If answers to 2 and 3 are yes, radiography is not indicated.
How sensitive and specific is this rule? Steill et al JAMA 2001 found this rule had 100% sensitivity and 42.5% specificity.
Signs and Sx of Acute Whiplash injury acute-can be asymptomatic-fx is immediate pain, soft tissue injury can take 24-48 hrs-pain is diffuse
Signs and SX of subacute whiplash injury? subacute-pain is starting to subside along with inflammation-now pain is more local and more specific
Signs and sx of chronic post whiplash injury? Chronic symptoms post-whiplash: “Whiplash-associated disorder” (WAD)Medical/legal/social issues*Some studies have found segmental hypermobility, alar and transverse ligament (hold C1 and C2 )damage, and fatty infiltration of muscle in people with WAD
WAD presentation in the ER? usually leave wearing a ? ER: most often radiographs are negative.Patient is given a soft cervical collar.Follow-up with primary care provider or orthopedist often delayed. Best to begin PT soon after injury
Whiplash treatment-immobilization versus ROM Early ROM pts do better-pain free range
Cspine pain and dysfn etiology. List 3 Poor posture, cspine joint dysfn, cervial spine derangement
Explain poor posture as an etiology of cspine pain forward head e.g. using computer holding phone between neck and shoulder
Explain c spine jt dysfn as an etiology of cspine pain. capsular pattern ROM: symmetrical loss of rotation and lateral flexion and extension, flexion usually not limited but painful* *usually sign of “arthritis” of zagopophyseal joints
Explain c spine derangement as an etiology of cspine pain. *disc lesionannular tear,bulging disc,herniated disc,sequestration *zygapophyseal facet joint problemsimpingement,hypomobility,hypermobility*uncovertebral joints
What is somatic pain somatic pain-arising from a structure in the neck-NOT a referred pain
What is referred somatic pain? referred somatic pain: Cloward’s areas-usually in shoulder blades
Describe nerve root compression pain? (radicular pain)-felt down in the extremity
IE on a cspine pt includes: interview and hx *trauma-R/O fracture, disloc, subluxation *R/O non-musculoskeletal-Cancer-commonly metastatic; multiple myeloma*Visceral referred pain*psycho/social aspects*dx tests-xray
Spinal screening for cspine pt includes Cervical Spine involvement*Observation: posture, demeanor*ROM testing*Strength Testing: mid range isometric muscle testing*Neuro Testing,sensation,reflex*Spcl Tests*Jt play*Fn test: Neck Dis Index*Palpation*need to reproduce pts complaint
During a strength test on spinal screen, you may see one of these 4 results. *SPL: normal*SPF: minor muscle lesion*WPF: severe muscle lesion, cancer, or fracture*WPL: neurological deficit or total tear of musculotendinous unit
List 6 special tests done in the spine screening compression, distraction, shoulder abduction test, vertebral artery tests, ULTT, spinal stability tests
VAT-vertebral artery test used to rule out? sx of this condition are? test reliable? vertebral basilar insufficiency (VBI).Sx VBI: dizziness, light-headedness, nausea, numbness to the face, slurred speech, nystagmus, blurred vision.Clinical tests unreliable:extension-rotation test has a sensitivity of about 0 (high false (-)
Mechanical Testing of Cspine-McKenzie Approach *Sustained positions: postural cause of sx*Pain end range: dysfn-maybe need stretching*Pain during mvt: derangement problem in spinal jts*Response to rpt movements-if sx go to neck while moving-good, if during motion pain goes to periphery-not good px
Is there a directional preference in McKz approach? Is there a “directional preference”?if sx worsen-they need to avoid that mvt, if the other side motion makes sx better-need to do rpt motion to that side
Describe Cervicogenic headaches headaches of cervical spine origin are common (upper C-spine referral of pain)signs and symptoms of C-spine involvement may have concurrent TMJ involvement,consider psychological factors (stress at work or at home)
Assessment of results at IE-what do you decide? PT indicated? referral required? dx tests needed? signs of spinal cord involvement? Are they in constant pain-sleep?sx do not respond to exam?acute/sub/chronic? irritability sx? motivation?meds?other interventions?PPattern?fit a clinical prediction rule?
What are signs of spinal cord involvement? *Spastic gait(+) *pathologic reflexes: Hoffman’s, Babinski *Bilateral extrasegmental paresthesias
Reasons affecting motivation for PT? direct access to PT,referred by other practitioner,out of work,litigation,MVA,slip & fall,injured at work,fear of serious pathology
Treatment principles for cspine trauma, pain, and dysfn-Acute acute symptoms: address pain and suffering*Modalities*Immobilization vs. AROM exercises*Modification of activities ADL, Work activities, recreational activities*Education*address fears, emphasize likelihood of recovery, prevent recurrence
Treatment principles for cspine trauma, pain, and dysfn-Subacute 1. minimize use of modalities2. emphasis on restoration of normal posture and movement depending on diagnostic category: posture syndrome,dysfunction syndrome,derangement syndrome
Treatment principles for cspine trauma, pain, and dysfn-Chronic -prob need referral to psychologist -address work probs-fitness: flexibility, strength, endurance-little modalities used-promote pos approach to treatmentfrequent re-assessment; stop PT if cant document progress; refer to appr practitioner
List PT interventions used on Cspine *modalities: heat, cold, electrotherapy, ultrasound, laser, traction*manual therapy: massage, passive stretching, myofascial release, joint mobilization and manipulation*postural correction*exercise
Exercise is used when treating Cspine to? *stretching *Strengthening-longus capitis and coli most common weakness of neck ms are ant.*correction of derangement*correction of muscle imbalances and faulty biomechanics*physical fitness*stress reduction
evidence for early intervention? Specific exercises may be effective for acute and chronic, Exercise should concentrate on cervical and shoulder-thoracic muscles,Exercise and manual therapy effective in reducing pain and improving function
Cervical spine instability evidence shows? intolerance to prolonged static postures,fatigue and inability to hold head up,better with external support (hands or collar),frequent need for self-manipulation,feeling of instability, lack of control,frequent acute attacks sharp pain c sudden mvts
Cervical Spine instability results of a PT exam: Poor coordination/neuromuscular controlPoor recruitment and dissociation of cervical segments with movement,Abnormal joint play,Motion is not smooth throughout the range,Aberrent movement
Reasons to have poor neck flexor endurance? What test determines ms endurance for neck flexors? Poor endurance of neck flexor muscles related to poor posture, neck pain, and cervicogenic headaches*Craniocervical flexion test using an inflatable air-filled pressure biofeedback sensor to determine muscle endurance
Psychosocial risk reduction intervention is effective in? improving function and facilitating return to work in people who are at a risk for prolonged pain-related disability.
Clinical Practice Guidelines are established by? Orthopedic Section of the APTA established guidelines for the treatment of neck pain.These guidelines are linked to the International Classification of Functioning, Disability, and Health (ICF)
ICF impairment-based categories of neck pain: Neck pain with mobility deficits.Neck pain with headaches.Neck pain with movement coordination impairments.Neck pain with radiating pain
Olson's text classification of cspine pain Cervical hypomobility,Cervical radiculopathy,Cervical instability,Acute pain (including whiplash),Cervicogenic headache
Physical Exam Measures Most Useful for Classification C-spine Active ROM,C-spine and T-spine segmental mobility,Cranial cervical flexion test using pressure biofeedback device,Neck flexor muscle endurance test,ULTT,Spurling’s Test,Distraction Test
Outcome Measures Neck Disability Index (NDI) See Figure 2-4 in Manual Physical Therapy of the SpinePatient-Specific Functional Scale (PSFS)Identify baseline status of functionMonitor change in patient’s statusTrack outcomes/determine success of plan of care
LOE for cspine mob/manip strong
LOE for Tspine mob/manip weak
LOE for stretching exercises weak
LOE for coordination, strengthening, and endurance exercises strong
LOW for centralization exercises weak
LOE for nerve mob mod
LOE cspine tx:mechanical and intermittent mod
LOE pt educ and counseling:early return to work, good px for recovery strong
Patients who are likely to have an immediate response to C-spine high-velocity thrust manipulation. See Box 6-2 in Olson’s textbook. Patients who are likely to benefit from thoracic spine manipulation for relief of neck pain. See Box 6-3 in Olson’s textbook.
Surgery affective for cspine pain? May relieve pain &disability over the shortterm for treatment of cspine radiculopathy,No justification for surgery for pt c axial neck pain without radiculopathy.Epidural&selective nerve root injections of steroids may shortterm imprvt of radicular sx
Can neck pain be prevented? Exercise may help prevent neck pain; there is no evidence that education, ergonomics, or risk factor modification is effective. Well-designed head restraint systems might prevent whiplash-associated disorders
cervical facet jt injections effective? no evidence
radiofrequency neurotomy effective? no evidence
serious complications of surgery? 4%
Created by: PTROCKS