Lecture 6: MSK Management II
Terms in this set (77)
Clinical Red Flags are based on what 2 things?
1) Organic pathology
2) Concurrent medical problems
Clinical Yellow Flags are based on what 6 things?
1) Iatrogenic factors: relating to illness caused by medical examination or treatment.
3) Coping strategies
5) Illness behavior
6) Willingness to change
Occupational blue flags are based on what 4 social and economic factors?
1) Family reinforcement
2) Work status
3) Health benefits and insurance
Socio-occupational black flags are based on what 4 occupational factors?
1) Working satisfaction
2) Working conditions
3) Work characteristics
4) Social policy
What are 6 attitudes and beliefs associated with clinical yellow flags?
1) pain is harmful or disabling
2) All pain must be abolished before returning to activity
3) Expectation of increased pain with work/activity
4) Expecting the worst
5) Pain is uncontrollable
6) Passive attitude to rehab
What are 6 behaviors associated with clinical yellow flags?
1) Extended rest (laying on the couch)
2) Reduced activity level
3) High pain
4) Excessive reliance on braces/crutches/collars (with neck pain)
5) Poor sleep quality (naps during the day)
What are 4 Screening and Outcome Measures for Neck pain?
1) Neck Disability Index
2) Patient Specific Functional Scale (PSFS)
3) Global Rating of Change (GROC)
4) Impact of even scale (IES)
What are the two classification systems that come up with dx for the different kinds of neck pain?
The ICD dx of cervicalgia is associated with the ICF of
neck pain with mobility impairments
What are 2 tests/measures used to asses Cervicalgia/Neck pain with mobility impairments?
1) Cervical AROM
2) Cervical and thoracic segmental mobility
The ICD dx of headaches or cervico-cranial syndrome is associated with the ICF of?
neck pain with headaches
What are 3 tests/measures used to assess headaches or cervico-cranial syndrome/neck pain with headaches?
1) Cervical AROM
2) Cervical segmental mobility
3) Cranial Cervical Flexion Test
The ICD dx of sprain and strain of cervical spine is associated with the ICF of
neck pain with movement coordination impairments
What are the 2 tests and measures that are good for assessing sprain&strain of cervical spine/neck pain with movement coordination impairments?
1) Cranial cervical flexion test
2) Deep neck flexor endurance
the ICD of spondylosis with radiculopathy or cervical disc disorder with radiculopathy is associated with ICF of
neck pain with radiating pain
What are 3 tests/measures used to assess spondylosis with radiculopathy or cervical disc disorder with radiculopathy/neck pain with radiating pain
1) Upper limb tension test
2) Spurling's test
3) Distraction test
Clinical Findings for Neck Pain with Mobility Deficits/Decreased ROM (4)
2) What type neck pain? Time of pain?
3) Where are the symptoms?
1) Younger individuals (age < 50 years)
2) Acute neck pain (duration < 12 weeks)
3) Symptoms isolated to the neck
4) and/or restricted cervical ROM
5 Clinical Findings for Neck Pain with Headache
1) unilateral headache associated with neck/suboccipital area symptoms that are aggravated by neck movements or positions
2) headache produced or aggravated with provocation of the ipsilateral posterior cervical myofascia and joints
3) restricted cervical range of motion
4) restricted cervical segmental mobility, and/or
5) abnormal/substandard performance on the cranial cervical flexion test
Neck Pain with Movement Coordination Impairments: what is the main goal?
Increased exercise tolerance and conditioning
5 Clinical Findings for Neck Pain with Movement Coordination Impairments
1) Length of pain?
2) Findings on CCFT?
3) Findings of Deep Flexor Endurance Test?
4) Coordination, strength and endurance deficits of what muscles?
5) Ergonomic ____ when performing ___ activities
1) Long standing neck pain (>12 weeks)
2) Abnormal/substandard performance on cranial cervical flexion test
3) Abnormal/substandard performance on the deep flexor endurance test
4) coordination, strength, and endurance deficits of neck and upper quarter muscles (all scalenes, upper trap, LS, pec minor, pec major) and/or
5) Ergonomic inefficiencies with performing repetitive activities
4 Clinical Findings of Neck Pain with Radiating Pain (Centralization)
1) Where are the symptoms? What tests aggravate the pain? Which help?
2) ____ cervical rotation (_ ___) toward ____side
3) Signs of N____ ___ ___
4) Success of ____ upper extremity symptoms with ____ ____ and ___
1) Upper extremity symptoms, usually radicular or referred pain that are produced or aggravated with spurling's maneuver and upper limb neurodynamic tests, and reduced with neck distraction test
2) Decreased cervical rotation (<60) toward involved side
3) signs of nerve root compression
4) success of reducing upper extremity symptoms with initial examination and intervention procedures
Joint Mobilization: Grade 1
small amplitude rhythmic oscillating mobilization in early range of movement
Joint Mobilization: Grade 2
large amplitude rhythmic oscillating mobilization in midrange of movement
Joint Mobilization: Grade 3
large amplitude rhythmic oscillating mobilization to point of limitation in range of movement
Joint Mobilization: Grade 4
small amplitude rhythmic oscillating mobilization at end range of movement
Joint Mobilization: Grade 5 (Thrust Manipulation)
small amplitude, quick thrust at endrange of movement
What are two interventions to help decreased neck pain and increase mobility?
1) C and T spine joint mobilization/manipulation
2) AROM exercises
T/F It is better to do joint mobilizations/manipulations without exercise
false, it is a class A recommendation to do both
What type of recommendation is thoracic spine thrust mobilization?
In the Development of a Clinical Predication Rule for Guiding Treatment of a Subgroup of Patients with Neck Pain study: a specific sub group was studied:
-Symptoms <30 days
- No symptoms distal to shoulder
- Looking up does not aggrevate symptoms
- FABQPA < 12
- Diminished upper thoracic kyphosis
- Cervical extension ROM < 30 degrees
was the clinical predication rule supported for this study?
IT WAS NOT SUPPORTED
-Found that ALL patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability than with people who received exercise only
2 Interventions to Centralize Pain
1) Repeated movements to centralize symptoms (extension and traction)
3 Types of Cervical Traction
What type of evidence is it?
What are the 2 types of modes of cervical traction?
2) Intermittent: force applied and then 2/3 released
2 Benefits of Manual Traction
1) more specific
2) easier to adjust force
3 Types of Mechanical Traction
1) Sub-occipital grip
2) Head halter over door
3) Pronex pneumatic traction unit
5 Mechanical Effects of Traction
1) Distraction of the v___ ___
2) Distraction of the f___ ___
3) Increased ___ tension/stretch of j____ __ and t___ and s____ m___
4) Widening of the ___ ___
5) Straightening of the s____ c____
1) Distraction/separation of the vertebral bodies
2) Distraction of facet joints (zygapophyseal)
3) Increased ligamentous tension/stretch joint capsules and tendons and spinal muscles
4) Widening of the intervertebral foramen
5) Straightening of the spinal curves
3 Physiological Effects of Traction
1) Increase circulation
2) Mechanoreceptor input
3) Decrease pain
4 Indications for Traction
3) Joint/Facet Hypombility
4) Muscle Guarding
Goal for Traction
maximum symptoms reduction and CENTRALIZATION of symptoms
5 Contraindications for Traction
1) S___ D___
2) V___ C__
1) Structural disease: tumor or infectious (fx, severe osteoporosis, TB of the bone, bone tumors)
2) Vascular compromise
3) Any time movement is CI (recent fusion, ligamentous rupture, evidence of instability)
4) Impaired cognitive function
How much time should traction be used for acute conditions/HNP?
How much time should traction be used for other conditions?
How much force should be used in traction?
8-10 lbs or 7-10% of patient's body weight, or enough force necessary to cause centralization of symptoms
Angle of pull for traction at C1-C5
0-5 degrees of flexion
Angle of pull for traction at C5-C7
25-30 degrees of flexion
Would you want flexion for HNP?
No! Keep neutral if it hurts
When using a manual traction device on a table what positioning do you want to use?
Knees in hooklying, with knees and hip flexed
5 Indicators that A Patient Would Benefit From Traction
1) P_____ with lower cervical spine mobility testing ____-___
2) Positive shoulder _____ test
4) Positive u____ ___ ___ test A
5) positive ____ ___ test
1) Peripheralization with lower cervical spine mobility testing C4-C7
2) Positive shoulder ABD test (hand on held helps symptoms)
3) Age > 55
4) Positive upper limb tension test A
5) Positive neck distraction test
T/F Adding mechanical traction to exercise for patients with cervical radiculopathy resulted in lower disability and pain, particularly at long term follow up
true, can rent them
T/F Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache
true, class a recommendation
(specific strengthening of the neck, ST and shoulder for chronic neck pain and headaches)
Neck Stabilization Exercise Guidance and Progression Example
•Always maintain neutral position of lumbar and cervical spine
Phase I: Localized contractions of deep neck muscles with chin tuck, progress to slight lift.
Phase II: Multi-limb, dynamic; examples are, alternate arms/legs on knees, prone T's and Y's with head support in neutral.
Phase III: Multi-plane, dynamic, functional; examples and diagonal TB patterns, and prone activities with unsupported head.
With neck stabilization exercises the lumbar and cervical spine should always remain in?
C-Spine isometrics exercise parameters
hold 10 seconds x 10 reps in all direction
education for neck pain (3)
1) B___ m___
1) Body mechanics
9 Other Interventions for Neck Pain
1) Mulligan techniques
2) Muscle energy
3) Strain counter strain
5) Intrument assisted STM
6) Dry needling
Parameters of the Mulligan Concept
P: pain free
I: instant result
LL: long lasting
SNAGS (Sustained Natural Apophyseal Glides)
therapist applies the appropriate zygapophyseal glide while the patient performs the symptomatic movement
(must result in pain free movement)
NAGS (Natural Apophyseal Glides (NAGS)
- used for cervical and upper thoracic spine
- consists of oscillatory mobilizations instead of sustained glides with SNAGs, and it can be applied to facet joints between C2 and T3
- mid range to end range facet joint mobilizations applied antero-superiorly along the treatment planes of joint selected
SMWLMS (Spinal Moblization with Limb Movement)
a transverse pressure is applied to the side of the relevant SP as the patient concurrently moves the limb through the previously restricted range of movement
Muscle energy techniques
(use muscle to mobilize joints)
- use voluntary muscle contractions exerted against a precise counter force to increase joint ROM
How does muscle energy work? (3)
1) Joint mobilization force
2) Post isometric muscle relaxation (autogenic inhibition)
3) Reciprocal inhibition
Technique of Muscle Energy (6)
1) Engage restrictive barrier in all planes
2) Provide gentle isometric resistance (in direction we want to restore)
3) Hold for 5-10 seconds
4) wait for complete relaxation of muscle
5) Reposition to engage in new barriers
6) repeat sequence
Strain Counterstrain Principle
put muscle in shortened position
Technique of Strain Counterstrain Technique (3)
1) Locate and palpate the tender point while the involved muscle is passively shortened
2) Once the position of max relaxation is found hold for 90-120 seconds
3) slowly return to resting position
T/F A multimodal tx of combining cervical manipulation and mobilization for exercise is more effective for reducing neck pain, headache, and disability than manipulation and mobs
true, best tx
Improvements influenced most by: (3)
2) symptom duration
3) inclusion of?
1) Age < 65
2) Symptom duration < 1 mo
3) Inclusion of manual therapies
5-9.5 points or 10-18% for neck pain
7-8.5 points or 14-17% for cervical radiculopathy
2 points for patients with cervical radiculopathy
each statement relates to a number on a 15 point scale, a rating of no change (8) is the mid point
pain intensity scale-current, best, worst last 24 hours
NDI: 0-4 points
NDI: 5-14 points (10-28%)
15-24 points (30-48%)
Dx Criteria to Discharge Neck Pain (7)
1) Functional ___/___
5) ____ activity lvl
6) ____ HEP
7) ____ posture
8) Non _____
1) Functional stability/endurance
2) Pain 2/10
3) 80% ROM
4) Strength 4/5
5) Premorbid activity lvl
6) Independent HEP
7) Balanced Posture
8) Non improvement
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THIS SET IS OFTEN IN FOLDERS WITH...
Lecture 1: C-Spine
Lecture 2: C-spine
Lecture 3: Medical Screening for Cervical Spine
Lecture 4: Cervical Spine Diagnoses/Disorders