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Terms in this set (100)
most common population of pts with neck pain
prevalence of neck pain in us
neck pain second only to LBP
TBC ( treatment based classification system of the neck
Mobility (manip, mobil, and exercise to increase mobilty), centralization( exercises/traction/manip to centralize), pain control, headache control, conditioning/ex tolerance
common red flag: diameter of spinal cord narrowed to cause compression of spinal cord. sx's: sensory changes in hand start distally and progress proximally (stocking glovein feet and hands) , instrinsic muscle wasting, and unsteady walking. occ non dermatomal le sensation., hyperreflexia, + hoffman, and clonus and babinski, +B and B. progressive disorder needing surgery
red flag but rare. age>50 , previous hx of CA, no relief with tx or bedrest. unexplained weight loss
most common cancers that met to spine
breast, lung and prostate
dxs that present with incompentent or unstable upper cspine
downes and RA (50%), falls in elderly, and mva in young
sxs of upper cervical ligamentous instabilty:
occipital HA's and numbness sometimes wtih severe restriction of cspine AROM.
Red flags for VBI
dizziness, diplopia, dysarthria, disphagia , and drop attacks.
other sx's of VBI inlcude
nystagmus, altered sendation, loss of visual acuity, imapired sensation of face and altered taste.
clinical prediction rule for xrays when to:
1. if pt can't actively rotate neck in 45 degrees either direction. 2. more than 65 yrs old.3 paresthesias in UE/LE 4. dangerous mechanism of injury. 5. If can't sit, walk, bad mva, has midline tenderness at cspine then you can't assess ROM and send to xray.
What visceral causes may refer to neck and mimic mechanical pain?
apical tumor of lung ( due to compression of Brachial plex) CAD (C3 distribution)
increased risk of prolonged pain and disabilty due to pyschosocial factors. FEAR AVOIDANCE BELIEFS MOST IMPORTANT!
deltoid, lat forearm and bicep reflex C5
Biceps, thumb, and brachioradialis C6
tricep (elbow ext and wrist flex) flexor carpi radialis, middle fingers, tricep C7
thumb ab (abd pollicus brevis), little finger, NA
medial (ulna) forearm sensation, hand instrinsics( dorsal interossi)
Most powerful predictor of disability and chronic pain:
leg pain and inability to centralize pain
conditioning classification is composed of which pts?
pts with instablity, pt's who sx's return frequenhty after short term improvements with PT, longer duration of sx', no ROM or centralization issues. lower pain/disability scores.
severe pain that severe affects ADL's and they don't tol any form of manual or movement based interveiont with high pain levels...diff to even do a PT exam. many have whiplash
usually due to trauma..may have referred pain into UE's.
very recent onset of pain.
TX with gentle arom within tol. modalities, act modification, Rom to adjacent areas.
no referred sx's, restriction RoM in SB and rotation, no signs of nerve compression .
Reduce HA classification
Chief HA c/o of cervicogenic origin which you can tell by: unilateral HA, sxs start in neck and progress to fronto ocular ara. pn triggered by neck movement or postion or by pressure on ipsilateral post neck. usually related to stiff and painful C1 C2 with muscle tightness.
signs of nerve root compression and referred UE c/o's; peripherazliation/centralizationof pn with movement.
tx centralization: traction and repeated movements
how do you tx mobility classifiction
MT and AROM ex's.
neck medical screening questionare
includes questions meant to possibly contraindict tx (yellow or red flags)
numeric pain rating scale
2 point difference shown to be valid improvement in pt status. can also use to match to current mechanics and sx's.
can help with pt classification, ID yellow flags, etc.
NDI sig. score?
neck disability index. 60% score is indication that yellow or red flags may be present or that possible serious neck condition present. all functional questions.
patient specific functional scale is
alternative to NDI just five functional activities that they pick. 2 point difference sig, improvement
high score high fears
+ hoffman and babinski, hyperreflexia of UE/LE, sensory chagnes in a nondermatomal pattern, clonus at ankle, weakness below level of compression, gait clumsiness. neuron goes from brain to spinal cord.
diminished or absent DTR's, decreased sensatio0n to light touch in a dermatomal pattern and muscle weakness along a specific dermatome. goes from spinal cord to muscle.
2+ normal 1+ present but diminished 0 absent 3+ hyperactive 4+ hyperreflexive- sign of UMN path
flick distal middle finger..if 1st or 2nd digit flexes sign of umn such as cord compression or intracranial pathology
VERY SENSITIVE 100%
Alar ligament test
PT stabilizes sp of axis and sb's head away from stabilizing hand. PT should feel sp move imm into her hand..if there is a lag it is suggestive of injury to alar ligament. no studies on validity.
sharp purser test
tests criform ligament or transverse ligament of the dens. ID's subluxation of atlas on axis (used orig for RA and AS pts. One hand stab sp of axis and other hand pushs head (in 20-30 degrees flex) posterior . + tessst if head felt to slide post which is relocation of formerly subluxed atlas on axis. .96 specificity and more sensitive as more pronounced
best tx for acute neck pain
gentle arom exs
non thrust technique
describes techniques that are mobil/manip
manip high velocity amp
cold hypersensitivity is a sign of
underlyilng more serious condition
which rib is typical?
stretch levator scap
ipsileral arm abd and SB away from arm
most common site of cervical radiculopahty?
CT , MRI and plain xrays will show what ?
pathoanatomic diagnosis in 19-75% of asymptomatic pts!
Cspine radiculopahty def?
a sesion or disease of cervical nerve root regarless of etiolgoy.
CPR for cervical radicuopathy?
+ ULT A (median biais)
+ spurling's test
+ distraction test ( up to 30#'s relieves sx's)
cervical rotation limited >60 degrees.
how specific is CPR for c radic?
3 or more rules met: moderate LR 6.1 or .94%
4 rules met .99% specific or 30.3 LR
how do you r/o c radiculpathy?
- ULT test A .97 sensitive
if involved side rotation is > 60 degrees sensitivity is .89%
how else can a patient report r/in c radiculopathy?
Where are your sx's most bothersome? pt states neck and scapular specificity .84
Neural tension tests false positives?
sig amount are false positives 86.9%?
Treatment of CR
no conclusive non conflicting results that any ONE nonoperative intervention or operative intervention effective.
TOS can be compressed by what structures?
1st rib, ant or medial scalene, pec minor
will measure length of what muscle for tos?
sxof TOS syndrome
C8/T1 or ulnar nerve distrib of sx's like parathesisas, pain, and weakness worse with postures that stress the NV bundle like elevation, protraction shlds
Exam a TOS pt for:
short hypertonic scalene muscles
short weak scap depressors
breathing ratio: diaphragm should intiate breathing and be a 2:1
+ULT ulnar nerve bias.
CFLR test performed how?
in sittinging passively rotate pt's head away from side being tested and then laterall flex ear to chest. + blocked movement due to hypomobility rib
How to tx TOS:
Lenghten tight muscles: scalense, levator, pec minor
teach diaghramatic breathing
mob 1st rib and tspine
neural gliding techniques
how do you stretch scalenes
tuck chin , sb away and rotate towards side
chance of disabilty in pt with s/p MVA is ?
chance of disabilty in s/p MVA with NDI >15% is
chance of disability in s/p MVA with Tampa scale of kinesiophobia score >41
If TSK<41 the risk decreases from 54% to 36%
Tx conditioning classification
aerobic ex and pre's for neck and UE muscles
do pts do better with tx if they are classified into neck categoreis and tx'd with matched intervention?
yes . mean ndi 5.6% better!
A tx's for neck pain are: (preponderance of level I/II studies to support)STRONG
mobilization/manip cervical spine
coordination, strengtheing and endurance exercises
"C" treatmetns are (single level II or bunch of LEvel III/IV with expert statements) WEAK
centralization, stretching, thoracic mobs/manips
% of people that have pathoanatomical lesion in imaging that are asymtp
pathoanatomical dx is _____ in majority of pt's with neck pain
what are poor indicators of success after neck surgery?
dermatomal sesnory loss on exam
preop use of weak narcotics
(lig pending .37 chance of success vsl. pt without ligation
good indicator of neck surgery success
working prior to surgery
prognosis of neck pain
50-85% of pt with neck pain will not fully recover
pt will continue to experience sx's 1-5 years after initial episode
rel minor trauma, negative imaging findings, neckpn/HA's, up to 48 hrs delayed onset, 57% recover in 3 monts, 8% never returnt o work
return to normal act ASAP, NSAID recommend but not muscle relas=x and narcrotics. collar for few days only, active mob in short arc->progress to isometric and deep flexor retraining as needed.
chronic whiplash>3 mo
multidisciplnary pain clinic appropriach usefule
CPR for thoracic HVLA for neck pain
generalized neck /shld pain<1 mo, significant improvement! but small sample size and 1 PT with limited generalizability
evidence based tx to cpsine
HVLA, mobs, MET, stretching, HEP, retaction, pnf, PRE's great outcomes!
thrust vs non thrust in cpsine?
no sig diff between thrust and non thrust in neck so:
try thrust tspine and cspine non thrust before cspine thrust to tx (b/c VBI)
CPR for cspine radiculopathy:
cspine rotation < 60 degrees
What does research say about short term outcome (28days) of pts with CR who receive tx?
If pt is <54 years old, dominant arm not affected, able to look down without pain, and tx consists >50% of time of traction, manual tx, and deep cspine flex strengthening pt will have 90% improvement with 4/4 and 85% with 3/4.
Which neck pain patients will improve with traction and exercise treatments?
age >55 yo
peripheralize sx's with c4-c7 mobility testing.
+ ULT A
+Shld abd test
4/5 95% improvement 3/5 79% improvement
neck distraction test
PT applies manual axial force of up to 30#s and pts sx's must decrease for +
shld abd test
In sitting pt places their hand on their head to support UE. + is allievation of pt's sx's
ULTT A median
in supine pt's arm positioned in scap depression, shld abd, shld ir, elbow ext , and wrist and finger ext.
cspine traction weight of head? max pull?
10-12 # and 40#
is there a stat sig between force of pull for success and non success for cspine traction?
NO! unable to establish parameters with RBE.
exerises for neck
1) posture: retract add scap and elongation cspine
2) DNF exercise: slow controlled craniocervical flex w/o SCM co contraction in supine
does cspine traction make a difference with treatment of neck pain?
two studies show no sig difference between groups that received traction vs. those that didn't.
unilateral, usually starts in neck and moves up, aggravated by neck postions or ROM.
What are research driven criteria to r/i or r/out CG HA's? (and are not present in tension ha or migraine) sn100% specific 94%
-weakness in CCFT, deep cervical flexor strength impairments
-lack of cspine ext
-painful palp of oa-C3/C4
other diagnostic findings for cervicogenic HA?
palpably painful C1/C2 joint dysfucntion
pect minor muscle length
Only 80% sensitive
Best treatment for CG HA's?
manual therapy and exercise
What interventions are best to decrease HA duration?
combo of MT + EX
HA frequency and intensity and neck pain all respond well to ?
Ex, MT and combo of EX and MT.
Medication use decreased by what tx?
all three : MT, EX, and combo.
If a pt at risk for VBI, will ex alone help?
yes, ex has excellent results if can't do MT.
Research shows what is best for CG HA's?
laser, soft tissue or MT
effiacy of self snag tx with belt for HA's?
Excellent increases in ROM and decreased HAk
flexion rotation test
overal best tx for neck and CG HA's
MT + EX
treat pt with referred pain below elbow x 6 weeks , 38 yo and no nerve root compression with:
mechanical traction: sx's distal to elbow and >30 days (two key elements)
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