Amanda Notes - Cervical Spine Treatment PDF

Cervical Spine Treatment Research A systematic review & meta-analysis of randomized trials regarding therapeutic exercise following cervical spine injury found 1,268 studies during the search. Of these more than one-thousand studies, only nine studies met inclusion criteria. Therapeutic exercises in...

Cervical Spine Treatment Research A systematic review & meta-analysis of randomized trials regarding therapeutic exercise following cervical spine injury found 1,268 studies during the search. Of these more than one-thousand studies, only nine studies met inclusion criteria. Therapeutic exercises included in the studies were strength training for the cervical spine, strengthening of the shoulder (GHJ and STJ) musculature, postural education / training, and stretching. These individual studies are shown in the summary tables below. The tables show the number of subjects included in the study (N), the specific treatment intervention(s), and the clinically-significant (CS) and/or statistically-significant (SS) findings. The researchers concluded that therapeutic exercise has a medium and significant short-term (at 1 month) and intermediate-term (between 1-6 months) effect on pain. They also concluded that therapeutic exercise has a medium and not statistically significant short-term (at 1 month) and intermediate-term (between 1-6 months) effect on disability. Only one study investigated found effects of therapeutic exercise at follow-up beyond 6 months. Based on these findings, clinicians should include therapeutic exercises, including strengthening and stretching, in the treatment programs of patients with cervical spine pain and/or disability. Cervical Spine Posterior Derangement Posterior derangements of the cervical spine can result from trauma, whiplash mechanism of injury or force-flexion mechanism of injury, or can be the result of insidious onset, due to poor posture. Like in the lumbar spine, posterior derangements present with the following single and repeated range of motion findings. Motion(s) Single ROM Repeated ROM Protrusion / Flexion Nil PDM ^ (P) W PDM Retraction / Extension Min / Mod ERP Initial Findings: ^ NW ERP Later Findings: v AB Cervical spine special tests that will be positive for an increase in pain include the Valsalva Maneuver, Cervical Compression Test, Spurling's Compression Test, and Quadrant Test. Cervical spine special tests that will be positive for a decrease in cervical spine pain include the Shoulder Abduction Test and the Cervical Distraction Test. Treatment of cervical spine posterior derangements follow the same procedures as treatment of posterior derangements in the lumbar spine. Step One: Reduction of the herniation using repeated retraction / extension exercises to end-range of motion. ○ This step is performed immediately and is the central part of the patient's treatment program. Step Two: Maintenance of herniation reduction using repeated retraction / extension exercises to end-range of motion, coupled with patient education about proper posture and body mechanics and postural correction using a lumbar roll and / or cervical roll. ○ This step is performed on day one of treatment and is also a central part of the patient's treatment program. ○ Steps one and two should continue for two weeks after the patient is pain-free / symptom-free to allow for healing of the damaged annulus fibrosis. Step Three: Recovery of Function using repeated protraction / flexion exercises to regain motion into flexion and prevent a flexion dysfunction from developing. ○ Step three should begin only after the patient has been pain-free / symptom-free for a period of two weeks. ○ Step three should be discontinued immediately if the patient's pain or symptoms return. ○ Flexion exercises should be avoided during the first three hours after waking and should always be followed with a set of extension exercises. Step Four: Prophylaxis and Prevention using a combination of patient education regarding posture and body mechanics, along with modification of activities of daily living, work environment, and sport-activity to prevent secondary injury. Treatment of cervical spine posterior derangements should include the following progression. Clinicians should start with the exercises at the top of the list and should progress to the next exercise only as necessary, if the patient fails to respond positively or plateaus during treatment. 1) Retraction in sitting (with or without overpressure) (10x / hour) 2) Extension in sitting (10x / hour) 3) Retraction / Extension in sitting (with or without overpressure) (10x / hour) 4) Retraction in lying (10x / hour)  5) Extension in lying (10x / hour) 6) Retraction / Extension in lying (10 x / hour) 7) Traction / Retraction / Extension in lying (10 x / hour) 8) Extension Mobilizations (P/A Mobilizations) Clinical Application: Using yourself as the patient, practice performing: a) seated retraction to end-range, b) seated retraction with over-pressure, c) seated extension, and d) seated retraction with extension to end-range. After completing these exercises in sitting, try performing them in supine as well with your head resting on the table for retraction and off the edge of the table for extension. The videos below demonstrate treatment procedures for cervical spine retraction and retraction with extension in sitting. These same procedures can be completed in supine lying. When completing these exercises in lying, retraction can be performed with the head resting on the table, while extension and retraction with extension exercises should be performed with the head off the end of the table (see the image at the bottom of the page). When performing retraction with extension in sitting or lying, the patient or clinician should hold the chin in a retracted position for as long as possible when completing the extension movement. As the neck moves further into extension, the retraction overpressure will be lost. Traction with Retraction and Extension and Cervical Spine PA mobilizations will be taught and practiced during the Summer Institute. Cervical Spine Anterior Derangement Cervical spine anterior derangement is the result of traumatic mechanism of injury, such as whiplash. Like in the lumbar spine, anterior derangements are far less common than posterior derangements. Single and repeated ROM findings for anterior derangements are shown in the table below. Recall that anterior derangements do NOT refer pain to the upper extremity, so pain production will not occur with repeated retraction or extension. Motion(s) Single ROM Repeated ROM Protrusion / Flexion Min / Mod ERP Initial Findings: ^ NW ERP Later Findings: v AB Retraction / Extension Nil PDM ^ W PDM Cervical spine special tests that will be positive for an increase in pain include the Valsalva Maneuver, Cervical Compression Test, Spurling's Compression Test, and Quadrant Test. Cervical spine special tests that will be positive for a decrease in cervical spine pain include the Shoulder Abduction Test and the Cervical Distraction Test. Treatment of cervical spine anterior derangements should include the following progression. Clinicians should start with the exercises at the top of the list and should progress to the next exercise only as necessary, if the patient fails to respond positively or plateaus during treatment. Flexion in sitting (10 x / hour) Flexion in sitting with overpressure (10 x / hour) Flexion mobilizations (PA Mobilizations) Cervical Spine Postural Syndrome Postural syndrome occurs insidiously due to prolonged poor posture when sitting (or standing). Patients will only report neck pain, no peripheralization, when positioned in forward head posture for extended periods of time. Recall that this condition is described as abnormal stress on normal tissue. Since tissue is normal, simply changing the patient's posture will immediately relieve the patient's neck pain. Single and repeated range of motion findings are shown in the table below. Motion(s) Single ROM Repeated ROM Protrusion / Flexion Nil NE Retraction / Extension Nil NE Cervical spine special tests that will be positive for an increase in pain include only sustained positioning tests in seated forward head posture. This sustained position will typically result in neck pain after 5-10 minutes. Correcting this forward head position will immediately relieve the patient's symptoms. Treatment of postural syndrome should include all of the following: Correct posture ○ Lumbar roll for sitting ○ Cervical roll for sleeping (as needed if sleeping exacerbates pain) Patient education regarding proper posture Ergonomic assessment ○ Lumbar roll for sitting ○ Headrest while driving Slouch / Overcorrect Exercises (15 times per hour to increase postural awareness) ○ This exercise involves instructing the patient to exaggerate the slumped sitting position and then over-correct this position by sitting up as tall as possible. ○ This exercise is used to create postural awareness in the patient. Computer Ergonomics Modification of computer work stations is a critical component in the treatment of both posterior derangements of the cervical spine and postural syndrome. The following list of twelve recommendations for modifying the computer station ergonomics should be used in clinical practice. Use a good chair with a dynamic chair back and sit back in the chair (consider the addition of a lumbar roll) Position the top of the monitor casing 2-3" (5-8 cm) above eye level Use no glare on screen or use an optical glass anti-glare filter where needed Sit at arms length from computer monitor Position feet on the floor or on a stable footrest Use a document holder, preferably in-line with the computer screen Rest wrists flat and straight in relation to forearms to use keyboard/mouse/input device Position arms and elbows relaxed and close to body Center the monitor and keyboard directly in front of you Use a negative tilt keyboard tray with an upper mouse platform or downward tilted platform adjacent to keyboard Use a stable work surface and stable (no bounce) keyboard tray Take frequent short breaks while working ("microbreaks") Modifications should also be made to driving posture, including using a lumbar support, placing the occiput against the headrest, and adjusting rearview mirrors to prevent forward head posture. Cervical Spine Flexion Dysfunction Cervical spine flexion dysfunctions occur insidiously following posterior derangement in the spine. In cases where patients fail to regain flexion after reducing spine pain, patients develop a loss of flexion range of motion. By definition, flexion dysfunctions refer to conditions in which the patient loses flexion range of motion. Patients with flexion dysfunctions will only report neck pain, without peripheralization. Recall also that patient with flexion dysfunction will have a baseline finding of 0/10 cervical spine pain. The table below shows the single and repeated range of motion findings for patients with flexion dysfunction. Protrusion may cause symptoms in patients with flexion dysfunctions, but in most cases will not result in pain. Motion Single ROM Repeated ROM Protrusion Nil NE Retraction Nil NE Flexion Min / Mod ERP ^ NW ERP Extension Nil NE The only cervical spine special test that will be positive for an increase in neck pain is the Cervical Hyperflexion Test. Treatment of cervical spine flexion dysfunction should include the following exercises. Clinicians should prescribe all of these exercises, this is not an exercise progression. Flexion in sitting to end-range of motion (2-3 x 60 seconds) Flexion in sitting to end-range of motion with overpressure (2-3 x 60 seconds) SNAGs for cervical spine flexion Flexion mobilizations (PA Mobilizations) Recall that if flexion dysfunction is secondary to a previous posterior derangement, do not allow the patient to flex the first 3 hours after waking and always follow flexion exercises with extension exercises. Cervical Spine Extension Dysfunction Cervical spine extension dysfunctions occur insidiously following anterior derangement in the spine or following repeated facet dysfunction. In cases where patients fail to regain extension after reducing spine pain, patients develop a loss of extension range of motion. By definition, extension dysfunctions refer to conditions in which the patient loses extension range of motion. Patients with extension dysfunctions will only report neck pain, without peripheralization. As is the case with the lumbar spine, cervical spine extension dysfunctions are far less common than cervical spine flexion dysfunctions. Recall also that patient with extension dysfunction will have a baseline finding of 0/10 cervical spine pain. The table below shows the single and repeated range of motion findings for patients with extension dysfunction. Retraction may cause symptoms in patients with extension dysfunctions, but in most cases will not result in pain. Motion Single ROM Repeated ROM Protrusion Nil NE Retraction Nil NE Flexion Nil NE Extension Min / Mod ERP ^ NW ERP The only cervical spine special test that will be positive for an increase in neck pain is the Cervical Hyperextension Test. Treatment of cervical spine extension dysfunction should include the following exercises. Clinicians should prescribe the first three exercises for patients with extension dysfunctions. Exercises four through six below can be used as necessary to regain full extension range of motion. Retraction in sitting or lying (2-3 x 60 seconds) Extension in sitting or lying (2-3 x 60 seconds) Retraction / Extension in sitting or lying (2-3 x 60 seconds) Traction / Retraction / Extension in lying (2-3 x 60 seconds) SNAGs for cervical spine extension Extension Mobilizations (PA Mobilizations) SNAGs for cervical spine extension and Cervical Spine PA mobilizations will be taught and practiced during the Summer Institute. The videos below demonstrate SNAGs for cervical extension and Self-SNAGs for cervical extension. Cervical Spine Adherent Nerve Root Cervical spine adherent nerve roots (ANR) occur insidiously in patients with a history of surgical intervention for disc herniation (anterior or posterior derangements) and in patients who have been immobilized in a cervical collar following traumatic neck injury (e.g. whiplash or fracture). Recall that adherent nerve roots are considered flexion dysfunctions with peripheralization of symptoms. Therefore, patients experiencing ANR will report radiating pain along the involved nerve root pattern (dermatome) and will demonstrate a loss of cervical flexion range of motion. The table below shows single and repeated ROM findings for patients suffering from cervical spine ANR. Like with flexion dysfunction, protrusion may cause symptoms, but more likely does not in the case of ANR. Recall also that patient with ANR will have a baseline finding of 0/10 cervical spine pain. Motion Single ROM Repeated ROM Protrusion Nil NE Retraction Nil NE Flexion Min / Mod ERP ^ P NW ERP Extension Nil NE Recall that the finding of ^ P NW ERP only will occur with an adherent or entrapped nerve root (ENR). This finding in flexion indicates an ANR and this finding in extension indicates an ENR (discussed on the next page in this module). The following cervical spine special tests will be positive for an increase in symptoms in the presence of an ANR: Elvy's (Brachial Plexus) Test, Cervical Hyperflexion Test, and the Slump (Slouch) Test. Treatment of cervical spine ANR should include the following exercises. Clinicians should prescribe all of these exercises, this is not an exercise progression. Neurodynamics for the upper extremity ○ May involve any combination of median nerve, radial nerve, and/or ulnar nerve exercises Flexion in sitting with overpressure (10x / hour) Contralateral side-bending with overpressure (10 x / hour) Combination flexion, side-bending, and rotation with overpressure (10 x / hour) The images below show the three range of motion exercises described above. These are each range of motion exercises with the patient moving to the end-range of motion with each repetition. These are NOT held at end-range like a stretching exercise. Cervical Spine Entrapped Nerve Root Cervical spine entrapped nerve roots (ENR) occur insidiously in patients experiencing whiplash or facet dysfunction. Entrapped nerve roots are considered to be extension dysfunctions with peripheralization of symptoms. Therefore, patients experiencing ENR will report radiating pain along the involved nerve root pattern (dermatome) and will demonstrate a loss of cervical extension range of motion. The table below shows single and repeated ROM findings for patients suffering from cervical spine ENR. In the presence of an ENR, symptoms will demonstrate ^P NW during the initial few repetitions of retraction and/or extension but will quickly become ^ P W as the number of repetitions increases (sometimes with fewer than five repetitions). Due to the nerve being inflamed and entrapped, patients will typically have cervical spine and peripheral symptoms even at baseline. Motion Single ROM Repeated ROM Protrusion Nil NE Retraction Min / Mod ERP ^ P NW ERP or ^ P W ERP Flexion Nil NE Extension Min / Mod ERP ^ P NW ERP or ^ P W ERP Recall that the finding of ^ P NW ERP is a red light (due to the production of new symptoms). Clinicians should discontinue RROM testing in retraction and extension immediately upon finding symptoms of ^P NW in an effort to prevent the nerve from becoming more compressed and more irritated with repeated ROM assessment. The following cervical spine special tests will be positive for an increase in symptoms in the presence of a cervical spine ENR: Cervical Hyperextension Test, Cervical Compression Test, Spurling's Compression Test, and Quadrant Test. The following cervical spine special tests will be positive for a relief of symptoms in the presence of a cervical spine ENR: Shoulder Abduction Test and Cervical Distraction Test. Treatment of cervical spine ENR should include the following exercises. Clinicians should prescribe all of these exercises, this is not an exercise progression. Flexion in sitting or lying with or without overpressure (10 x / hour) Contralateral side-bending with or without overpressure (10 x / hour) Contralateral rotation with or without overpressure (10 x / hour) Combination of flexion, side-bending & rotation with or without overpressure (10 x / hour) Therapeutic Modalities to decrease nerve inflammation NSAIDs The images below show the four range of motion exercises described above. These are each range of motion exercises with the patient moving to the end-range of motion with each repetition, overpressure may be added to the exercise at the end-range of motion as desired in order to open the facets. These exercises are NOT held at end-range like a stretching exercise. Cervical Spine Facet Syndrome Cervical spine facet syndrome is one of the most common pathologies seen in the cervical spine. Facet dysfunction most commonly is associated with insidious onset due to poor sleeping positions, poor posture, or repetitive activities involving lateral flexion and rotation in work or activities of daily living. Two common mechanisms of injury for facet dysfunction are shown below. Facet dysfunction in the workplace can be prevented with the use of headsets or phone modifications to limit the amount of cervical spine lateral flexion experienced by the user. The slide below shows options for preventing cervical spine facet syndrome by altering workplace ergonomics. Facet dysfunction can be the result of trauma to the cervical spine (e.g. whiplash injury or axial load injury) causing compression and inflammation of the facet joint. Facet dysfunction may involve either a locked facet (which will result in significant loss of range of motion) or an inflamed facet (which will result in end-range pain and only minor loss of range of motion). The table below shows single and repeated ROM findings for patients suffering from lower cervical spine facet dysfunction. In the presence of a facet dysfunction, pain will be isolated to the spine and will not radiate into the upper extremities. Motion Single ROM Repeated ROM Protrusion Nil NE Retraction Nil ERP or Min / Mod ^ W ERP ERP Flexion Nil NE Extension Nil ERP or Min / Mod ^ W ERP ERP Ipsilateral Lateral Flexion Nil ERP or Min / Mod ^ W ERP ERP Contralateral Lateral Flexion Nil NE Ipsilateral Rotation Nil ERP or Min / Mod ^ W ERP ERP Contralateral Rotation Nil NE Recall that lower cervical spine facets are closed with retraction, extension, ipsilateral lateral flexion, and ipsilateral rotation. Therefore, each of these motions will result in end-range pain. Repeated motions that close the facet will cause a worsening (W) of pain as the repetitions increase in number. The following cervical spine special tests will be positive for an increase in symptoms in the presence of a cervical spine facet dysfunction include Cervical Compression Test, Spurling's Compression Test, and Quadrant Test. The Cervical Distraction Test may provide a temporary relief of pain due to an opening of the involved facet joint. Treatment of cervical spine facet syndrome should include the following exercises. Clinicians should prescribe all of these exercises, this is not an exercise progression. If the facet is locked, manual therapy techniques should be used to unlock the facet first ○ Three-Component Facet Mobilization / Manipulation ○ SNAGs for Rotation (direct or indirect techniques) ○ Self SNAG for Rotation ○ Muscle Energy Techniques for Facet Dysfunction Flexion in sitting or lying with or without overpressure (2-3 x 60 seconds) Contralateral side-bending with or without overpressure (2-3 x 60 seconds) Contralateral rotation with or without overpressure (2-3 x 60 seconds) Combination of flexion, side-bending & rotation with or without overpressure (2-3 x 60 seconds) Therapeutic Modalities to decrease pain and inflammation NSAIDs The images below show the four stretching exercises described above. Each of these exercises involves the patient holding the position at end-range of motion, with or without overpressure, for 60 seconds, in order to open the inflamed facet joint(s).