Week 10 - Cervical Rehabilitation PDF

# Cervical Rehabilitation ## Musculoskeletal Rehabilitation, Assessment, and Treatment (MRAT211) ## Causes - Osteoarthritis - Discogenic disorders - Trauma - Tumors - Infection - Myofascial pain syndrome - Torticollis - Whiplash - Congenital deformities ## Cervical Spondylosis, Spinal Stenosis a...

# Cervical Rehabilitation ## Musculoskeletal Rehabilitation, Assessment, and Treatment (MRAT211) ## Causes - Osteoarthritis - Discogenic disorders - Trauma - Tumors - Infection - Myofascial pain syndrome - Torticollis - Whiplash - Congenital deformities ## Cervical Spondylosis, Spinal Stenosis and Cervical Disc Herniation | Feature | Cervical Spondylosis | Cervical Spinal Stenosis | Cervical Disc Herniation | |-----------------------------------|----------------------|--------------------------|---------------------------| | Pain | Unilateral | Unilateral or bilateral | Unilateral (MC) or bilateral | | Distribution of pain | Into affected dermatomes | Usually several dermatomes affected | Into affected dermatomes | | Pain on extension | Increases | Increases | May increase (MC) | | Pain on flexion | Decreases | Decreases | May increase or decrease (MC) | | Pain relieved by rest | No | Yes | No | | Age group affected | 60% >45yr, 85% >65yr | 11-70yr, MC:30-60yr | 17-60yr | | Instability | Possible | No | No | | Levels commonly affected | C5-C6, C6-C7 | Varies | C5-C6 | | Onset | Slow | Slow, may be combined with spondylosis or disc herniation | Sudden | ## Myofascial Pain Syndromes "Regional pain syndrome characterized by muscle pain caused by MTrPs.” **Signs & Symptoms** - **Motor aspect** - Disturbed motor function - Muscle weakness - Stiffness - LOM - **Sensory aspect** - Referred pain - Local tenderness - Peripheral & central sensitization - Allodynia - hyperalgesia ## Myofascial Trigger Points - Minimum Criteria: - Taut band - Trigger point in that taut band ## Indications for Inactivation of Myofascial Trigger Points - Unable to identify the underlying pathology of MTrP activation. - Failure in treating the underlying pathologic lesion. - Persistent pain or tightness resulting from MTrP even after complete elimination of the underlying pathology. - Intolerable pain resulting from MTrP. - Pain or discomfort interfering with functional activity. ## Fibromyalgia “Chronic condition characterized by widespread pain that covers half the body (right or left half, upper or lower half) and has lasted for more than 3 months.” - Noninflammatory condition: - generalized musculoskeletal pain - tenderness to touch in a large number of specific areas of the body - wide array of associated symptoms ## Primary and Secondary Fibromyalgia - **Primary Fibromyalgia**: “PURE” FMS having no association with any other medical condition - **Secondary Fibromyalgia**: Associated with another medical condition - Example: RA, SLE, hypothyroidism ## Co-morbidities - Depression - Anxiety - Insomnia - Cognitive dysfunction - Chronic fatigue - Endocrinopathies - Irritable bowel syndrome - Dysfunction of the autonomic system ## Clinical Signs & Symptoms - Widespread pain lasting more than 3 months. - Widespread local tenderness. ## Primary Musculoskeletal Symptoms - Aches and pains - Stiffness - Swelling in soft tissue - Tender points - Muscle spasms or nodules An illustration is included on page 11 showing points on a human body representing the primary musculoskeletal symptoms. ## Aggravating Factors and Relieved By **Aggravating Factors** - Cold - Stress - Excessive or no exercise - Physical activity (overstretching) **Relieved By** - Warmth or heat - Rest - Exercise (gentle stretching) ## Clinical Signs and Symptoms - Myalgia (generalized aching) - Fatigue (mental and physical) - Sleep disturbances, nocturnal myoclonus, nocturnal bruxism - Tender points of palpation - Chest wall pain mimicking angina pectoris - Tendinitis, bursitis - Temperature dysregulation - Raynaud’s phenomenon; cold-induces vasospasm (hypersensitivity to cold) - Hypothermia (mild decrease in core body temperature) - Dyspnea, dizziness, syncope - Headache (throbbing occipital pain) ## Differentiating MPS from FMS | Feature | MPS | FMS | |-----------------------------------|--------------------------|--------------------------------------------------------------------| | Trigger points | Trigger points | Tender points | | | Localized musculoskeletal condition | Systemic condition | | | No associated signs and symptoms | Wide array of associated signs and symptoms | | Etiology | Overuse, repetitive motions; reduced muscle activity | Neurohormonal imbalance; autonomic nevous system dysfunction | ## Cervical Strains & Sprains (Whiplash Injury) **Manifestations** - Pain is the chief complaint. - Local tenderness. - Decreased range of motion. - Headaches, typically occipital. - Blurred or double vision. - Dysphagia, hoarseness, jaw pain, difficulty with balance, vertigo. ## Cervical Fractures - Occipital condyle fracture. - Occipito-cervical dislocation. - C1 ring fracture. - C2 pars interarticularis. - C2 Odontoid process fracture. - Wedge compression fracture. - Burst and compression-flexion (tear-drop) fracture. ## C1 Ring Fracture - MOI: axial compression with elements of hyperextension and asymmetric loading of condyles. - **Manifestations**: - Vertebral artery injuries may cause basilar insufficiency: vertigo, blurred vision, and nystagmus. - Associated with injury to cranial nerves VI–XII and neurapraxia of the suboccipital and greater occipital nerves. - Neck pain or a feeling of "instability" - Jefferson fracture: a 4-part fracture of the atlas. - MC injuries 2-part and 3-part. ## C2 Pars Interarticularis - AKA Hangman's fracture. - MOI: hyperextension and axial load. - **Manifestations**: - Pain, instability, or both are present. - Patient may have neurologic compromise. - May be associated with cranial nerve, vertebral artery, or craniofacial injuries. - Disruption of the C2-C3 disk causes marked instability. An illustration is included on page 20 showing different types of C2 Odontoid process fracture. ## Symptoms - Pain: May refer to the shoulders and arm. - Stiffness. - Deformity: Wry neck or excessive flexion or extension. - Numbness, tingling & weakness: Nerve root impingement. - Headache. - Tension. ## Signs - No examination of the neck is complete without examination of the upper trunk, both upper limbs, and shoulder joints. ## Patient History - **What is the patient's age?** - **What are the symptoms, and which are most severe?** - **What was the mechanism of injury? Was the patient moving when the injury occurred?** - **Has the patient had neck pain before?** - **What is the patient’s usual activity or pastime? Do any particular activities or postures bother the patient?** - **Did the head strike anything, or did the patient lose consciousness?** - **Did the symptoms come on right away?** - **What are the sites and boundaries of the pain?** - **Is there any radiation of pain?** - **Is the pain affected by laughing, coughing, sneezing, or straining?** - **Does the patient have any headaches? If so, where? How frequently do they occur?** - **Does a position change alter the headache or pain? If so, which positions increase or decrease the pain?** - **Is paresthesia (a “pins and needles" feeling) present?** - **Does the patient experience any tingling in the extremities?** - **Are there any lower limb symptoms?** - **Does the patient have any difficulty walking? Does the patient have problems with balance?** - **Does the patient experience dizziness, faintness, or seizures?** - **Does the patient exhibit or complain of any sympathetic symptoms?** - **Is the condition improving, worsening or staying the same?** - **Which activities aggravate the problem? Which activities ease the problem?** - **Does the patient complain of any restrictions when performing movements?** - **Is the patient a mouth breather?** - **Is there any difficulty in swallowing (dysphagia), or have there been any voice changes?** - **What can be learned about the patient’s sleeping position?** - **Does the patient display any cognitive dysfunction?** A table showing the differential diagnosis of cervical spondylosis, spinal stenosis, and disc herniation is included on page 23. A table with warning signs and symptoms of serious cervical spine disorders (red flags) is included on page 26. A table including clinical yellow flags indicating heightened fear-avoidance beliefs is included on page 27. A table showing a differential diagnosis of cervical nerve root and brachial plexus lesion is included on page 29. A table including signs and symptoms of vertebrobasilar artery insufficiency is included on page 32. ## Look - Search for deformities: - Wryneck - Stiffness Images are included on page 35, showing how to assess the neck for deformities. ## Observation - Head and Neck Posture: An illustration is included on page 36 showing different views of the head and neck. - Shoulder levels. - Muscle spasm or any asymmetry. - Facial expression. - Boney and soft-tissue contours. - Evidence of ischemia in either upper limb. - Normal sitting. ## Feel - Anterior Cervical Muscles: - Longus capitis and longus colli muscles. - Scaleneus anterior, medius, and posterior muscles. - Sternocleidomastoid muscles. - Posterior Cervical Muscles: - Suboccipital muscles. - Transversospinal muscles. - Erector Spinae Muscles. ## Palpation - Flat palpation - Pincer palpation An image is included on page 39, showing examples of flat and pincer palpation methods. Images are included on pages 40 and 41, showing the anterior muscles of the neck. ## Examination ### Active Movements - Flexion - Extension - Side flexion left and right - Rotation left and right - Combined movements - Repetitive movements - Sustained positions ### Passive Movements A table is included on page 42 of movement restriction and possible causes when examining passive movements. ## Cervical Myotomes - Neck flexion: C1 to C2. - Neck side flexion: C3 and cranial nerve XI. - Shoulder elevation: C4 and cranial nerve XI. - Shoulder abduction/shoulder lateral rotation: C5. - Elbow flexion and/or wrist extension: C6. - Elbow extension and/or wrist flexion: C7. - Thumb extension and/or ulnar deviation: C8. - Abduction and/or adduction of hand intrinsics: T1. ## Functional Assessment of the Cervical Spine - **Breathing**: Normal, unlabored breathing should be seen with the mouth closed; no gulping or gasping. - **Swallowing**: A complex movement involving muscles of the lips, tongue, jaw, soft palate, pharynx, and larynx as well as the suprahyoid and infrahyoid muscles. - **Looking Up at the Ceiling**: At least 40° to 50° of neck extension is usually necessary for everyday activities. If this range is not available, the patient will bend the back or the knees, or both, to obtain the desired range. - **Looking Down at Belt Buckle or Shoe Laces**: At least 60° to 70° of neck flexion is necessary. If this range is not available, the patient will flex the back to complete the task. - **Shoulder Check**: At least 60° to 70° of cervical rotation is necessary. If this range is not available, the patient will rotate the trunk to accomplish this task. - **Tuck Chin In**: This action produces upper cervical flexion with lower cervical extension. - **Poke Chin Out**: This action produces upper cervical extension with lower cervical flexion. - **Neck Strength**: In athletes, neck strength should be approximately 30% of body weight to decrease chance of injury. - **Paresthesia**: Referred to the hands, may make cooking and handling utensils particularly difficult or even dangerous. ## Functional Tests A table is included on page 48 of a range of functional test that assess the functioning of the cervical spine. <start_of_image>functional test ## Outcome Measures - **Neck Disability Index (NDI):** Capture perceived disability in patients with neck pain. - **Patient-Specific Functional Scale (PSFS):** Alternative or supplement to generic condition-specific measures. ## Cervical Active Range of Motion - The amount of active neck flexion, extension, rotation, and side bending motion measured using an inclinometer. ## Cervical and Thoracic Segmental Mobility - With the patient in prone, cervical and thoracic pine segmental movement and pain response are assessed. - Assess the mobility of each joint using the thumb (cervical) and hypothenar (thoracic) to check each joint. ## Cranial Cervical Flexion Test - Using pressure biofeedback inflated to 20mmHg. - Give pressure (22, 24, 26, 28 and 30mmHg). - Should maintain 10 secs each stage. - Abnormal response: - Is unable to generate an increase in pressure of at least 6 mmHg. - Is unable to hold the generated pressure for 10 secs. - Uses superficial neck muscles to accomplish the cervical flexion. - Uses a sudden movement of the chin or pushing the neck forcefully against the pressure device. ## Neck Flexor Muscle Endurance Test - In supine, the ability to lift the head and neck against gravity for an extended period. - Supine, hook-lying position. - With the chin maximally retracted and maintained isometrically. - Pt. lifts head and neck until head is ~1 inch above plinth keeping chin retracted to the chest. ## Special Tests - Foraminal Compression (Spurling’s) Test. - Upper Limb Tension Test (ULTT). - Jackson Compression Test. - Distraction Test. - Shoulder Abduction Relief Test. - Valsalva Test. - Tinel’s for Brachial Plexus. - Romberg's Test. - Tinel’s for Brachial Plexus. - Romberg's Test. - Lhermitte's Sign. - Vertebral Artery (Cervical Quadrant) Test. - Hautant's Test. - Naffziger's Test. - Sharp-Purser Test. - Transverse Ligament Stress Test. ## Physical Therapy Intervention - Cervical Manipulation/Mobilization: Should be performed as an adjunct to exercise. - Thoracic Mobilization/Manipulation. - Stretching: Anterior, medial, posterior scalenes; upper trapezius; levator scapulae; pectoralis minor; and pectoralis major. - Coordination, Strengthening, and Endurance Exercises. - Voluntary contraction and release methods: - Muscle energy technique. - Reciprocal inhibition. - Post-isometric relaxation. - Upper Quarter and Neck Mobilization. - Traction. - Voluntary contraction and release methods: - Muscle energy technique. - Reciprocal inhibition. - Post-isometric relaxation. - Upper Quarter and Neck Mobilization. - Traction. This document provides a comprehensive overview of cervical rehabilitation and addresses various aspects, including causes, diagnosis, treatment, and functional assessment. The use of images and tables aids in visualizing the information and understanding the various procedures and techniques involved in cervical rehabilitation.