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MOD 8 : C-Spine
C-Spine Trauma, Pain, and Dysfunction
| Question | Answer |
|---|---|
| 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
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