Physical Therapy for Cervical Spine Disorders PDF

PHYSICAL THERAPY FOR CERVICAL SPINE DISORDERS BY: BISHOY LOBBOS OBJECTIVES By the end of this lecture, the student should be able to: ❑ Memorize the related clinical anatomy. ❑ Memorize the related clinical biomechanics. ❑ Identify the red flags of cervical spine. ❑ Recog...

PHYSICAL THERAPY FOR CERVICAL SPINE DISORDERS BY: BISHOY LOBBOS OBJECTIVES By the end of this lecture, the student should be able to: ❑ Memorize the related clinical anatomy. ❑ Memorize the related clinical biomechanics. ❑ Identify the red flags of cervical spine. ❑ Recognize and understand classification and treatment of cervical disorders FUNCTIONAL ANATOMY  The seven vertebrae of the cervical spine are divided into two groups according to structure and function.  The vertebrae of the lower cervical spine (C2–C7) are similar in structure to the vertebrae of the thoracic and lumbar spine with clearly defined vertebral bodies and spinous processes. The transverse processes has foramen to allow passage of the vertebral artery  From C3–T1 there is a total of 10 saddle-shaped, diarthrodial articulations between the uncinate process and the adjacent body know as uncovertebral joint, or joints of Luschka, which also facilitate mobility of the lower cervical spine.  The articular facet joints of the lower cervical spine are in the sagittal plane and incline forward at approximately 45°. This forward inclination allows the articular facet joints to bear weight and guides the motion of the segment.  THE ATLAS is a wide, thin ring of bone with a well-developed transverse process but no spinous process. There is no intervertebral disk  with concave joint surfaces above and below, serves the function of the disk.  The atlanto-occipital joint is the one true convex-on- concave joint in the spine. The superior articular facet surfaces of the atlas are oval and concave  AXIS  The inferior articular facet of C2 has the same form and function as the articular facets of the lower cervical spine. The joint surfaces of the superior articular facet of C2 are aligned in the horizontal plane to allow rotation. The dens portion of C2 is a vertical pin of bone that acts as a pivot around which the atlas LIGAMENTS  The anterior and posterior longitudinal ligaments and the ligamentum flavum are present in the cervical spine fromC2 through C7 and perform the same functions as in the thoracic and lumbar spine  The interspinous and supraspinous ligaments blend with the nuchal ligament of the cervical spine. The nuchal ligament has its origins on the spinous processes of the cervical spine and its insertion on the occiput.  Its function in humans is to prevent overflexion of the neck. The nuchal ligament tightens at the extreme of neck flexion. It also becomes tight, flattening out the cervical lordosis, with approximately 15° of nodding of the upper cervical spine NUCHAL LIGAMENT  The posterior longitudinal ligament ends at C2. The tectorial membrane, which is thin and diaphanous through the rest of the spine, thickens into tectorial ligament arising from C2, bypasses the atlas, and inserts on the occiput. The tectorial ligament becomes tight with flexion of the head. Deep to the tectorial ligament is the cruciform ligament, which has both vertical and transverse portions. The vertical portion of the cruciform ligament has its origin on C2 and has the same insertion and function as the tectorial ligament. The horizontal portion of the cruciform ligament has its origin and insertion on the interior surface of the anterior ring of the atlas. It encircle the dens to reinforce the transverse ligament of the atlas  The transverse ligament of the atlas has its origin and insertion on the interior surface of the anterior ring of the atlas. It encloses the dens and is lined with a synovial membrane and articular cartilage to provide lubrication as the atlas rotates around the dens.  The alar ligament is a winglike structure that has its origin on the lateral borders of the dens and its insertion on the occiput. It is a major portion of the stabilization system of the upper cervical spine. The configuration of the atlanto-occipital joints could allow considerable lateral flexion, which would damage the medulla oblongata.  The apical ligament has its origin on the tip of the dens and inserts on the occiput. It becomes taut when traction is applied to the head. The joint capsule of the atlanto- occipital joint is reinforced with ligaments. VIP  The ligaments of the upper cervical spine may be damaged in high-velocity accidents, weakened by rheumatoid arthritis or other types of systemic inflammatory diseases, or may be congenitally absent or malformed. Before any kind of mechanical treatment is begun, the integrity of the upper cervical ligament should be tested. traction or mobilization of the cervical spine should be considered gravely dangerous. TESTING LIGAMENTOUS INSTABILITY lateral flexion alar Sharp-Purser Test ligament stress test MUSCLES  The muscles of the cervical spine can be considered in four functional groups: superficial posterior, deep posterior, superficial anterior, and deep anterior. Normal function of the cervical spine depends on proper flexibility and balance of these muscle groups. POSTERIOR MUSCLES ANTERIOR MUSCLES  In an upright neutral posture, the cervical segments are supported by muscular sleeves formed by the longus colli muscle anteriorly and the semispinalis cervicis and cervical multifidus muscles posteriorly. In particular, the longus colli muscle has a major postural function in supporting and straightening of the cervical lordosis. In addition, the craniocervical region is supported by muscles that attached to the cranium and span the upper cervical motion segment, such as the longus capitus, rectus capitus anterior, and rectus capitus lateralis muscles (capital flexors) anteriorly and the suboccipital extensor, semispinalis and splenius capitis muscles ( capital extensors) posteriorly VERTEBRAL ARTERY  The vertebral arteries pass upward through the lateral foramen of the cervical vertebrae. There is a redundant portion that allows full rotation of the atlas in both directions.The vertebral arteries enter the cranium at the foramen magnum and come together to form the basilar artery.  maximum occlusion occurs with the combination of extension and rotation. Brief occlusion of the vertebral artery is not a problem in a patient who has normal carotid arteries and a normal circle of Willis; however, if there is interruption of the normal blood supply to the brain, occlusion of the vertebral artery may cause a reduction of blood flow to the brain stem and cerebellum, the symptoms of which are dizziness, nystagmus, slurring of speech, and loss of consciousness.  There are many well-documented cases of coma and death secondary to vasospasm or thrombosis of the vertebral arteries caused by manipulation of the upper cervical spine.  Before using traction or mobilization techniques on the upper cervical spine, the vertebral arteries should be tested carefully one at a time by placing the neck in full rotation, extension, and lateral flexion to each side and holding for approximately 1 minute. VERTEBRAL ARTERY TEST  The clinician should observe the patient for nystagmus, slurring of speech, blurring of vision, dizziness, or unconsciousness. Dizziness as a result of vertebral artery testing is fairly common and should be a warning sign to the practitioner to proceed very cautiously.  Nystagmus, slurring of speech or loss of consciousness should be considered contraindications to traction and mobilization of the neck, and the practitioner should take care when treating the patient to make sure that the neck is not positioned in extension or the extremes of rotation. FUNCTIONAL BIOMECHANICS  The occiput-C1 joints are formed by a pair of convex-shaped occipital condyles and the concave-shaped superior articular surfaces of the atlas. Therefore, the occipital condyles glide in the opposite direction of the motion direction, which follows the convex/concave rule.  A relative lateral flexion of the cranium occurs to the contralateral side of the cervical spine rotation, which functions to keep the eyes level with an axial rotation movement of the head.  The facet joints for C1-C2 are oriented more horizontally than the middle and lower cervical spine facet joints to allow greater mobility  the C1-C2 segment allows the greatest amount of rotation (approximately 50%).  The atlas glides in the relative opposite direction of the cervical rotation. During cervical lateral flexion, a relative rotation occurs to the opposite side of the lateral flexion at the C1-C2 and occiput-C1 segments to allow the face to remain facing forward in a frontal plane during the lateral flexion.  Middle and lower cervical rotation and lateral flexion motions are coupled motions from C2-T1, with lateral flexion and rotation occurring toward the same side. The axis of the motion is perpendicular to the angle of the cervical facet joints, with an upglide on the contralateral facet joint and a downglid on the ipsilateral facet joint.  clinically, motion is noted in the vertebral segments as caudal as T3-T4 with cervical active motion. The active and passive mobility of the upper thoracic spinal segments should be evaluated and treated with the cervical spine. FLEXION OF CERVICAL SPINE ROTATION OF THE CERVICAL SPINE LATERAL FLEXION OF THE CERVICAL SPINE CERVICAL RED FLAGS Cervical Myelopathy:  Sensory disturbance of hands  Muscle wasting of hand intrinsic muscles  Unsteady gait  Hyperreflexia  Bowel and bladder disturbances  Multisegmental weakness or sensory changes Neoplastic Conditions:  Age >50 years  History of cancer  Unexplained weight loss  Constant pain; no relief with bed rest  Night pain Upper Cervical Ligamentous Instability:  Occipital headache and numbness  Severe limitation during neck AROM in all directions  Signs of cervical myelopathy Inflammatory or Systemic Disease:  Temperature >37°C  Blood pressure >160/95 mm Hg  Resting pulse >100 bpm  Resting respiration >25 bpm  Fatigue Vertebral Artery Insufficiency:  Drop attacks  Dizziness  Lightheadedness related to head movements  Dysphasia  nystagmus, slurring of speech, blurring of vision,  unconsciousness  CLASSIFICATION OF CERVICAL SPINE DISORDERS  (1) ACUTE PAIN AND WHIPLASH ASSOCIATED DISORDERS  the acceleration-deceleration injury after a motor vehicle accident. It usually results from the collision of two automobiles but also can result from contact sports such as football or high-velocity sports such as skiing.  Recent history of trauma  High pain and disability score  Referred symptoms into upper quarter  Poor tolerance to examination and most intervention  A key feature regarding motor impairments of patients is muscle imbalance between superficial and deep neck muscles.  Higher levels of pain and disability, older age, cold hyperalgsia, impaired vasoconstriction, and moderate posttraumatic stress symptoms have been shown to be associated with poor outcomes 6 months after whiplash injury QUEBEC TASK FORCE CLASSIFICATION FOR WHIPLASH- ASSOCIATED DISORDERS (WAD) MANAGEMENT  Relative rest  Physical modalities  Intermittent use of cervical collar  Gentle AROM within patient tolerance  Activity modification to control pain  Gentle manual therapy and exercises, but avoidance of pain-inducing manual therapy techniques or exercises  (2) CLINICAL INSTABILITY  Remote history of trauma  Symptoms provoked with sustained weight-bearing posture  Symptoms relieved with non–weight-bearing postures  Hypermobility with loose end feel of mid cervical segments  Poor strength of cervical spine multifidus, longus colli, and longus capitus muscles  Shaking/poorly controlled (aberrant) motion with cervical active range of motion  Greater cervical active range of motion in supine (non–weight-bearing) position than in standing (weight bearing) position PATIENT COMPLAIN ( SYMPTOMS)  “intolerance to prolonged static postures” “fatigue and inability to hold head up”; “better with external support, including hands and collar”; “frequent need for self-manipulation”; “feeling of instability, shaking, or lack of control”; “frequent episodes of acute attacks”; and “sharp pain, possibly with sudden movements. BY EXAMINATION  Patients with neck pain due to clinical instability show a delay in DNF activation and display deficits in the postural endurance of these muscles and is associated with an increased activity in superficial flexor muscles leading to altered neuro-motor control strategy during craniocervical flexion. This alteration potentially compromises the cervical spine's control which may leave it vulnerable to further strain. So people with neck pain have more forward head position when distracted CRANIOCERVICAL FLEXION TEST (CCFT)  2 stages ( strength and endurance)  Normal performance is the achievement of pressure of at least 26 mm Hg with the pressure held steady for 10 seconds with 10 repetitions. Ideal performance is to successfully target and hold 28 to 30 mm Hg. MANAGEMENT  Postural education  Cervical stabilization exercise program  Mobilization/manipulation above and below hypermobilities  Ergonomic corrections  (3)CERVICAL RADICULOPATHY (CR)  Cervical radiculopathy (CR) is a disorder of the spinal nerve root commonly caused by cervical disc herniation or other space-occupying lesion, such as spondylitic spurs or cervical osteophytes, resulting in nerve root inflammation, impingement, or both. CR is usually present with pain in the neck and one arm, loss of motor function, or reflex changes in the distribution.  The most common cause of CR (in 70% to 75% of cases) is foraminal encroachment of the spinal nerve from a combination of factors, including decreased disc height and degenerative changes of the uncovertebral joints anteriorly and zygapophysial joints posteriorly (i.e., cervical spondylosis). Herniation of the intervertebral disc is responsible for only about 25% of the FINDINGS Positive Spurling’s A test Positive neck distraction test FINDINGS Positive ULNT 1