Cervical Spine TBC

Question 1

Neck Pain Impact

Answer 1

One-month prevalence of activity interfering neck pain is from 7.5% -14.5%. The 12-month prevalence of neck pain-limiting activities was estimated as 1.7% (limited ability to work due to neck pain) 2.4% (limited social activities due to neck pain) 11.5% (limited activities due to neck pain).

Question 2

Three levels of classification

Answer 2

1. First Level: Is the patient appropriate for physical therapy management? 2. Second Level: What is the level of acuity? (staging the patient) 3. Third Level: What treatment should be used? (classification)

Question 3

Red Flags - Spinal Fractures

Answer 3

Major trauma, severe limitation during active range in ALL directions

Question 4

Red Flags - Cervical Myelopathy

Answer 4

Sensory disturbance of the hands; Muscle wasting of hand intrinsic muscles; Unstead gait; Hoffman reflex (flick middle finger); hyperreflexia; bowel and bladder disturbances; multisegmental weakness, sensory changes, or both

Question 5

Red Flags - neoplastic conditions

Answer 5

Age over 50; previous history of cancer; unexplained weight loss; constant pain w/out relief at rest; night pain

Question 6

Red Flags - Upper Cervical ligamentous instability

Answer 6

Occipital headache and numbness; severe limitation during neck active range of motion in all directions; signs of cervical myelopathy

Question 7

Red Flags - Vertebral artery insufficiency

Answer 7

Drop attacks, dizziness, dysphagia, dysarthria, diplopia, positive cranial nerve signs

Question 8

Red Flags - Inflammatory or systemic disease

Answer 8

fever >100*F, BP >160/95 mmHg, resting pulse > 100 bpm, resting respiration >25 bpm, fatigue

Question 9

Red Flags - Vertebrobasilar Insufficiency

Answer 9

The Five D

Question 10

Yellow Flags

Answer 10

Belief that pain is harmful or disabling resulting in guarding and fear of movement; believe that all pain must be abolished before returning to work; expectation of increased pain with activity or work; lack of ability to predict capabilities; catastrophizing; belief that pain is uncontrollable; passive attitude toward rehab; use of extended rest; reduced activity level; withdrawal from daily activities; avoidance of normal activity and progressive substitution of lifestyle awy from productive activity; reports of extremely high pain intensity; excessive reliance on aids (eg braces or crutches); sleep quality reduced following onset of back/neck pain; high intake of alcohol or other substances with pain onset; smoking

Question 11

Stage 1 findings

Answer 11

substantial functional limitations that interfere with ADLs; difficulty concentrating at work, driving, reading for a prolonged period, or sleeping; NDI scores > 20%

Question 12

Stage 2 findings

Answer 12

Able to perform most ADLs without difficulty; unable to perform demanding or prolonged physical activity especially when attempting complex tasks; NDI <20%

Question 13

Mobility Classification

Answer 13

Recent onset of symptoms; no radicular signs/symptoms; no hx of surgery; age manual therapy and exercise; manipulation/mobilization of thoracic or cervical spine

Question 14

Centralization Classification

Answer 14

Radicular signs/symptoms; symptoms distal to elbow; peripheralization/centralization of symptoms with neck movements -> activities to promote centralization; mechanical or manual traction; repeated movement to centralize symptoms

Question 15

Exercise and Conditioning Classification

Answer 15

Longer duration of symptoms (>30 days); no signs of nerve root compression; lower pain and disability scores -> neck muscle strengthening; upper extremity strengthening

Question 16

Pain Control Classification

Answer 16

Recent traumatic onset (whiplash); high pain and disability scores; intolerance for most activities -> cervical mobilization; active range of motion; avoid cervical immobilization

Question 17

Reduce headache classification

Answer 17

chief complaint of headaches accompanying neck pain; headache affected by neck movement; no history or signs of migraine; unilateral headache; headache reproducible w/palpation to C0-3; restricted neck ROM -> manipulation/mobilization of the cervical spine; strengthening of the cervical deep neck flexors; scapular muscle strengthening

Question 18

Hoving et al NNT

Answer 18

3 for manual therapy, 7 for traditional therapy

Question 19

Costs

Answer 19

Manual therapy < traditional therapy < general practitioner

Question 20

Mobilization vs Manipulation

Answer 20

no significant difference!

Question 21

Manual techniques for cervical spine

Answer 21

mobilization, manipulation, muscle energy techniques

Question 22

Walker et al results

Answer 22

Manual therapy and exercise group only 22% sought follow up care, Minimal Intervention 46% sought follow up care

Question 23

Walker et al Conclusion

Answer 23

impairment-based manual therapy and exercise provides superior short and long term outcomes for MND patients

Question 24

Reference standard for success

Answer 24

quite a bit better, a great deal better, and a very great deal better -> statistically/clinically significant improvement

Question 25

Cleland validation study results

Answer 25

CPR did not identify patients likely to respond to thoracic spine manipulation (TSM); superior outcome for those receiving TSM; take home: TSM + EB strengthening program improves outcomes

Question 26

Puentedura thoracic vs cervical RCT results

Answer 26

cervical manip > thoracic manip

Question 27

Puentedura CPR for patients likely to benefit from cervical manips - CPR

Answer 27

CPR: ≥ 3 factors out of: symptoms 10* rotation diff, pain w/PA spring testing middle cervical spine

Question 28

Puentedura CPR for patients likely to benefit from cervical manips - results

Answer 28

NPRS significant decrease for CPR+ patients, probability of success inc from 38% to 90%

Question 29

Centralization Classification - activities to centralize movements

Answer 29

traction, repeated retraction

Question 30

Cervical radiculopathy tests

Answer 30

ipsalateral cervical rotation s test

Question 31

Centralization Classification interventions

Answer 31

cervical lateral glides, thoracic spine manipulation, strengthening exercises, intermittent cervical traction

Question 32

intermittent cervical traction parameters

Answer 32

starting at 18 lbs, increasing 1-2 lbs based on patient response; 15 minutes duration; 30/10 on/off time; cervical spine in ~25* flexion

Question 33

Raney CPR for cervical traction and exercise

Answer 33

3 of 5 of the following had a 79.2% chance of success (vs 44% w/no predictors): +distraction, age >55, + shoulder abduction test, +ULTT A, symptom peripheralization w/mobility testing of C4-7

Question 34

Ylinen active neck muscle training - Treatment

Answer 34

Strength: theraband resisted flexor exercise, shoulder/UE dumbbell ex, trunk/leg training, stretching, aerobic training; endurance training: supine head lifts (3x20), shoulder/UE dumbbell ex , trunk/leg training, stretching, aerobic training

Question 35

Ylinen active neck muscle training - Results

Answer 35

Theraband best

Question 36

Headache epidemiology

Answer 36

16% one day prevalence; 10-12% migraine annual; tension type 38% annual; significant cost due to missed work

Question 37

cervicogenic headache diff dx

Answer 37

unilateral without side shift; occipital to frontopatietal and orbital; chronic or episodic; moderate to severe; 1 hr to weeks duration; pain is non-throbbing, non-lancinating, usually starts in neck; triggered by neck movement, postures, pressure over C0-3; associated symptoms include decreased ROM and milder migraine-like symptoms

Question 38

migraine diff dx

Answer 38

60% unilateral with side shift; frontal, periorbital, temporal; 1-4 per month; moderate to severe;duration 4-72 hr, pain is throbbing/pulsating; multiple triggers, neck movement not usually one; associated symptoms: nausea, vomiting, visual changes, phonophobia, photophobia

Question 39

tension-type headache diff dx

Answer 39

diffuse bilateral; diffuse location; 1-30 per month; mild to moderate severity; last days to weeks; pain is dull; triggers are multiple, not usually neck movement; associated symptoms include decreased appetite, phonophobia, photophobia

Question 40

cranial cervical flexor endurance test

Answer 40

supine, avoid SCM activation, tuck chin without retraction; normal is 10 seconds w/out compensations

Question 41

neck flexor muscle endurance test

Answer 41

supine, patient tucks chin and elevates head; normal >38 seconds, pain <23 seconds

Question 42

Jull cervicogenic article results

Answer 42

manip + exercise = best outcomes;

Question 43

Jull cervicogenic article treatment

Answer 43

manual therapy: high/low velocity to specific cervical mobility restrictions; ther ex: low load endurance (longus capitus and colli in supine, serratus and lower trap), 2x daily, postural education throughout day

Question 44

Jull NNT

Answer 44

2.6 MT+Ther Ex; 3.4 MT only; 3.8 ther ex only

Question 45

Self mobs outcomes

Answer 45

immediate improvement in flexion-rotation test ROM of 15 degrees, decrease in headache severity at 4 and 12 months

Question 46

WAD chronicity

Answer 46

1/3 of patients progress to chronic WAD

Question 47

WAD prognosis

Answer 47

adreno-sensitive environments (car crash, work) worse prognosis

Question 48

Fritz TBC article

Answer 48

matched interventions better than therapist selected (73% vs 54% experienced detectable change) HOWEVER <50% matched