3. Classification for Pts w/ Neck Pain

Question 1

WHY classify neck pain?

Answer 1

• Generalized tx’s applied to all pts w/ neck pain are NOT going to yield predictable and effective outcomes
• So…classification into subgroups may yield better results

Question 2

Classification Subgroups for mechanically based interventions

Proposed intervention-based 5 Classification Groups based on hx and phys. exam: 5

Answer 2

1. Mobility
2. Centralization
3. Exercise and Conditioning
4. Reduce HA (cervicogenic)
5. Pain Control

*NOTE: You do not need to move pts from one to the other like LBP→ just find where they go

Question 3

RED FLAGS for Mechanically Based CS Interventions

Answer 3

KNOW THEM!!!

See chart for sx’s

• Cervical Myelopathy*
• Neoplastic Cond’s
• Upper Cervical Ligamentous Instability
• Vert AA Insuff
• Inflamm or Systemic Disease

Question 4

RED FLAGS

Cervical Myelopathy

Answer 4

• sensory disturbs in hands
• MM wasting of hand intrinsics
  
  • thenar em.
• unsteady gait
• Hoffman’s
• Hyperreflexia→ UMN
• B&B disturbs
• multisegmental weakness and/or sensory changes ex. LEs also

Question 5

RED FLAGS

Neoplastic Conds

Answer 5

• >50yo
• prev hx of cx
• unexplained wt loss
• constant pain, no relief w/ bed rest
• Night Pain***

Question 6

RED FLAGS

Upper Cervical Ligamentous Instability

Answer 6

• Occipital HA and numbness
• Severe limitation during neck and AROM in all directions
• signs of cervical myelopathy
• traumatic injury to neck not imaged

Question 7

RED FLAGS

Vert AA Insuff.

Answer 7

• drop attacks
• dizzy/lightheadedness related to neck mvmt
• dysphagia
• dysarthria
• diplopia
• • CN signs

Question 8

RED FLAGS

Inflamm or Systemic Disease

Answer 8

• Temp >37deg C
• BP >160/95mmHg
• Resting pulse >100bpm
• Resting respiration >25bpm
• Fatigue

Question 9

YELLOW FLAGS

*suggest that pt may have slower than expected response to tx OR less favorable prognosis for improvement

2

Answer 9

1. Attitudes and Beliefs
2. Behaviors

*These are clinical yellow flags indicating heightened fear-avoidance beliefs

Question 10

What should you remember about pain control subgroup?

Answer 10

Do NOT want them here long!!!

Question 11

Pain Control Subgroup

Classification, Exam findings, Intervents

Answer 11

• Classification:
  
  • Pain Control
• Exam Findings:
  
  • high pain/disability scores
  • very recent onset of sx’s
  • sx’s precipitated by trauma
  • referred or radiating sx’s extending into UQ
  • poor tol for exam or most interventions

Question 12

Additional proposed interventions:

Pain Control Subgroup

Answer 12

• Cervical mobs→ low grade/gentle; may include gentle manual traction if tolerated
• Massage→ reduce fluid stasis and mm spasm
• *Cervical collar for BRIEF Pd (<1wk)→ more harm than good

see pics for more on Cervical collar

Question 13

More Notes on Pain Control Subgroup

how should they be progressed?

Answer 13

• Pts in this subgroup should be progressed to one of the other subgroups as quickly as approp.
  
  • 1wk max, 2wks absolute max
• Wean off passive modalities and progress pts involvement w/ self-care and ex’s over the course of 1-2wks

Question 14

2 things about this subgroup

1. MOST pts end up here @ some point
2. Approp for MOST pts even if in other subgroups as well

Answer 14

Exercise and Conditioning

Question 15

Exercise and Conditioning Subgroup

Classification, Exam findings, Intervents

Answer 15

• Classification:
  
  • Conditioning and Incd Ex Tolerance
• Exam Findings:
  
  • lower pain/disability scores
  • longer duration sx’s
  • no signs nerve root compression
  • No peripheralization during ROM
• Interventions:
  
  • strength/endurance ex’s for mm’s of neck and UQ
  • Aerobic conditioning

Question 16

Additional Pt Profile/Exam Findings for Exercise and Conditioning Subgroup:

*not a rule, but generally….

Answer 16

• Sx’s present for >30d and/or pt is >60yo
• In gen, NON-radicular neck pain and no sig motion los
• ***If MVA or Whiplash:
  
  • event was >30d ago
  • if <30d ago→ initial pain and disability ratings relatively LOW***

Question 17

Related to Exercise and Conditioning Subgroup

Recent focus of research on the Deep Cervical Flexor Muscles (DCFMs)

Answer 17

• Demo’d DEC function in chronic neck pain
• Research findings show strong support for training of DCFM to reduce chronic neck pain w/ carry over @ 12months and 3yrs

Question 18

Strength and Conditioning Exercises

Deep Craniocervical flexor focused:

Answer 18

• practice of Craniocervical flexion test
• Ex’s use air cuff and test pos’s of CCFT for gen training and endurance→ focus on lvls (mmHg) the pt has diff w/ during the CCFT test
• *combined cervical flexion-craniocervical flexion exercise

Question 19

General Conditioning Ex’s

Answer 19

• Scap clocks
• Theraband rows → retraction/postural correction
• Brueggers for lower traps/dec upper trap activation
• Cervical retractions:
  
  • from prone
  • from quadruped
  • quadruped bird-dogs
  • into ball standing w/ alt UE mvmts; w/ cervical rotation
  • etc…

Question 20

Mobility (Mobilization) Subgroup

Classification, Exam findings, Interventions

Answer 20

• Classification:
  
  • Mobility
• Exam findings:
  
  • recent onset of sx’s
  • NO radicular/referred sx’s in UQ
  • restricted ROM w/ side-to-side rotation and discrepancy in L/F ROM
  • NO signs of nerve root compression OR periph. of sx’s in UQ w/ cervical ROM
• Interventions:
  
  • CS and TS mobs/manipulation***
  • AROM

*REMEMBER→ limtd ROM, NO contraind’s—→ manip CS & TS but should be part of a comprehensive tx program

Question 21

Mobility (Mobilization) Subgroup

Additional pt profile/exam findings

Answer 21

• RECENT (<30d) onset of mech. neck pain for reasons other than MVA/Whiplash
• IF MVA/Whiplash:
  
  • Onset <30d ago if relatively LOW initial pain and disability
  • NO s/s nerve root compression
    
    • UQ neuro screen clear; (-) spurlings, (-) ULTT, (-) distraction, (-) shoulder ABD
• In general, <60yo
  
  • NOTE: age >60yo is NOT a contraindication for mobilization

Question 22

Evidence in favor of mob/manip for pts w/ neck pain

(mobility subgroup evidence)

Bronfort et al, Evans et al, Hoving et al, Gross et al

Answer 22

Cochrane review→ suggests that mob/manip IS HELPFUL for some pts w/ neck pain

Question 23

Evidence in favor of mob/manip for pts w/ neck pain

(mobility subgroup evidence)

Hoving et al

Answer 23

Manual tx consisting of mobs (thrust and non-thrust) performed by PT was more effective in improving outcomes and more cost effective than PT tx that did not incorp a manual approach or than cont’d care by gen practitioner

Question 24

Evidence in favor of mob/manip for pts w/ neck pain

(mobility subgroup evidence)

Koes et al.

Answer 24

manip tends to be more helpful for younger pts w/ acute neck pain

*BUT age NOT contraindication

Question 25

**Thoracic Spine Manipulation** in pts w/ mech. neck pain who fit into **“Mobility” Subgroup** * Cleland et al explored CPR for subgroup pts (mobility/manip/mobilization subgroup) for improvement after TS manipulation * **Intervention was:** * **3 diff TS manips + CS ROM Ex's**

Answer 25

* 6 Factors from pts examination were found to be predictive of success→ DO NOT MEMORIZE or rigidly apply 1. **Sx's \<30days (strongest factor)** 2. No sx's distal to shoulder 3. Looking up does not aggravate sx's 4. Phys act score on FABQ \<12 5. Diminished upper TS kyphosis (weakest association) 6. Cervical EXT ROM \<30degs

Question 26

So…for **Mobility Subgroup** **The CPR was NOT valid** What do you do now?

Answer 26

* As long as **NO RED FLAGS or contraindications** present in pt w/ mech neck pain who seems to fit into “Mobility” Subgroup→ Try TS mobs/manips! * Important to monitor pt response so that if they are NOT improving, **you can modify approach as needed!**

Question 27

**Centralization Subgroup** **Classifcation, Exam findings, Interventions**

Answer 27

* **Classification:** * Centralization * **Exam Findings:** * Radicular/referred sxs in the UQ * \***Scapular sx's are BIG\*\*\*** * Peripheralization and/or central. of sx's w/ ROM * Signs of nerve root compression present * **May have pathoanatomic dx of cervical radiculopathy** * **Interventions:** * Mech/manual traction * Repeated mvmts to centralize → **directional pref**

Question 28

Signs of Nerve Root Compression:

Answer 28

* UQ myotomal weakness * Dec sensation in dermatomes * 0, 1+ DTRs * + Spurlings * + Shoulder ABD (Bacoti's) * + Distraction

Question 29

NOTE: Lumbar spine **traction and directional preference**

Answer 29

* In the L/S…**traction** and **directional preference** were 2 separate subgroups * In the C/S→ traction and direct. pref. ex's are **bundled together into “_Centralization”_ subgroup**

Question 30

Cervical Traction ## Footnote **Some notes…**

Answer 30

* TRY MANUAL TRACTION FIRST!!! * Active warmup * Manual tech's * THEN **workout!!!**→ have them work in **tissue altered state\*\*\*\*\***

Question 31

Literature: **Cervical Traction**

Answer 31

see pics * NOTE: **Take-home points:** * NO conclusions can be drawn about whether traction effective for neck and back pain * NO evidence that traction is more efficacious than other tx's * NO evidence that traction is ineffective tx for neck or back pain * **Evidence of Benefit:** Jellad demo'd superiority of **man. and mech. intermittent C/S traction** PLUS conventional tx vs. conventional tx in reducing radicular and cervical pain and disability * NOTE: **LOOK UP L/S REFRESHER** for: * proposed effects * **same w C/S AND L/S** * indications * contraindications

Question 32

C/S Traction: ## Footnote **Set Desired Parameters**

Answer 32

* Static vs. Intermittent (RARE) * Force * **Min: 10lbs** * **Max: up to 30lbs if tolerated** * **Conventional Wisdom:** @ least 25lbs to actually produce separation of VBs * Time * typ b/w 10-20mins * NOTE: transient soreness is normal

Question 33

Rotation and LF **to the side of sx's====**

Answer 33

More limited ROM

Question 34

**Directional Preference** **notes…**

Answer 34

* How to ID direct pref: * Centralization occurs? Peripheralization? * Reduction in sx's and/or improvement in ROM * **NOTE:** All pts that centralize **have a directional pref**, BUT NOT all pts that have a directional preference centralize!!!

Question 35

Peripheralization Guidelines for the UE

Answer 35

* Upper trap pain is **MORE CENTRALIZED** than scapula * Ex of pain pattern * Sx's in upper arm→ rep'd motions→ sx's in scapula=\> **Centralization** * Sx's in upper traps→ rep'd motions→ sx's in scapula=\> **Peripheralization**

Question 36

Ex. **Directional Preference Acts for Pts w/ _Retraction/Ext_ Preference** ## Footnote **SEATED**

Answer 36

* Use a **progression of force concept** for C/S retraction ex's * Ex. Progression below **assumes a pref for _retraction:_** * Seated (can also do supine) * Cervical retraction (common direct pref) * Cervical retraction w/ overpressure * Cervical retraction + Ext * Cervical retraction + Ext w/ oscillating rotations for overpressure * \***NOTE:** C/S retraction tolerance is the GOAL

Question 37

Ex. **Directional Preference Acts for Pts w/ _Retraction/Ext_ Preference** ## Footnote **SUPINE**

Answer 37

* Progression: * Retraction into pillow * Retraction off edge of plinth w/ head support * PT gen'd end range retraction of plinth * Traction + retraction off plinth * Traction + retraction + Ext \*\*\* * Traction + retraction + Ext + overpressure oscillating rotation

Question 38

Ex. **Directional Preference Acts for Pts w/ _Retraction/Ext_ Preference** ## Footnote **PRONE**

Answer 38

Common in HA pts * Retractions on elbows w/ chin resting on hands/fists

Question 39

**Cervicogenic HA Classification** **Classification, Exam findings, Interventions**

Answer 39

* **Classification:** * Reduce HA * **Exam findings:** * U/L HA w/ onset preceded by neck pain * HA pain triggered by neck mvmt or pos's * HA pain elicited by pressure on **post. neck** * Positional HA (ex. sitting @ counter) * **Interventions:** * C/S manips/mobs * Strengthening of neck and UQ mm's * Postural ed. * DCFM's * Lower traps (Brueggers!!!)

Question 40

**Jull et al (2002)** compared control group of HA pts w/ HA groups receiving either **c/s mobs/manips** OR **strengthening of deep neck and scap mm's,** OR **combined manual tx + exercise**

Answer 40

* All interventions tx groups showed **sig reductions** in HA compared to control * Improves **maintained @ 1-yr follow-up** * @ Short term follow up (7 and 12wks) the **combined ex. + manual tx groups** showed some advantage over other groups REVIEW C/S MOB TECHNIQUES!!! Used for cervicogenic HAs as well\*\*\*

Question 41

Cervicogenic HA Tx ## Footnote **Suboccipital Release**

Answer 41

see pics

Question 42

C/S Subgroups **Flow Chart**

Answer 42

USE IT!!!!!

Question 43

Neck pain assoc'd w/ **Poor Postural Habits** ## Footnote **Mckenzie's take on it…**

Answer 43

* referred to as **“postural syndrome”;** pts in this cat. typ tx'd w/ similar intervents used for the **exercise and conditioning subgroup** as well as **postural re-ed** * Examination may be clear, **as sx's are typ due to the pt spending prolonged pds in offending posture**

Question 44

Postural syndromes: ## Footnote **Exam may ALSO reveal what?**

Answer 44

* FHP * protracted shoulders * mm weakness in **trunk ext's, scap retractors and depressors, DCFMs** * tenderness and/or tightness and/or fibrosis \*NOTE: **ALL C/S pts→ screen scapula!!!!!!!**

Question 45

Postural Syndromes: **If FHP present:** might see findings listed in:

Answer 45

* upper traps, lev scap, rhomboids **due to chronic overstretch and overwork** * pec minor and suboccipitals **due to adaptive shortening** * MAY see ROM impairs assoc'd w/ **muscle tightness**

Question 46

**WHY do pts w/ neck pain often experience sx's related to muscular tightness/tension?**

Answer 46

FLOW CHART!!! ## Footnote **Get them into a subgroup!!!**