Week-10-Cervical-Rehabilitation-2 PDF

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

## Cervical Rehabilitation ### Musculoskeletal Rehabilitation, Assessment, and Treatment (MRAT211) ### Causes - Osteoarthritis - Discogenic disorders - Trauma - Tumors - Infection - Myofascial pain syndrome - Torticollis - Whiplash - Congenital deformities ### Cervical Rehabilitation Causes Table | Pain | Cervical Spondylosis | Cervical Spinal Stenosis | Cervical Disc Herniation | |--------------------|-------------------------|-----------------------------|-----------------------------| | Distribution of pain | Unilateral | Unilateral or bilateral | Unilateral (MC) or bilateral| | Pain on extension | Into affected dermatomes | Usually several dermatomes | Into affected dermatomes | | Pain on flexion | Increases | Increase | May increase (MC) | | | Decreases | Decreases | May increase or decrease (MC) | | Pain relieved by rest | No | Yes | No | | Age group affected | 60% of >45yr, 85% of >65yr | 11-70 yr, 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 Fribromyalgia "PURE” FMS having no association with any other medical condition ### Secondary Fribromyalgia 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 ### Site for Fibromyalgia A diagram of a female body is depicted with 18 tender points marked. Note that 7 of those points are located on the left side of the body. There is an accompanying note which states "7 area dapat masakit." ### Contraindications - Fracture - Bony spurs/tumor - Osteoporotic - Presence of trauma ### Aggravating factors - Cold - Stress - Excessive or no exercise - Physical activity (overstretching) ### Relieved by - Warmth or heat - Rest - Exercise (gentle stretching) ### Clinical Signs & 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 | | MPS | FMS | |-------------|-----------------------------|------------------------------------------| | Trigger points | Localized musculoskeletal | Tender points | | | condition | Systemic condition | | | No associated signs and symptoms | Wide array of associated signs and symptoms | | | Etiology: overuse, repetitive motions; reduced muscle activity | Etiology: neurohormonal imbalance; autonomic nervous 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 ### C2 Odontoid process fracture A diagram depicts three types of C2 Odontoid process fractures, labeled (a), (b), and (c). ### 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? - Memonze agad! Kunin yung ageng pt. - What are the symptoms, and which are most severe? - Chief complaint - What was the mechanism of injury? Was the patient moving when the injury occurred? - Static or may movement ba? - Has the patient had neck pain before? #### Differential Diagnosis of Cervical Spondylosis, Spinal Stenosis, and Disc Herniation | Pain | Cervical Spondylosis | Cervical Spinal Stenosis | Cervical Disc Herniation | |--------------------|--------------------------|-------------------------------|-----------------------------------| | Distribution of pain | Unilateral | Unilateral or bilateral | Unilateral (MC) or bilateral | | Pain on extension | Into affected dermatomes | Usually several dermatomes | Into affected dermatomes | | Pain on flexion | Increases | Increase | May increase (MC) | | | Decreases | Decreases | May increase or decrease (MC) | | Pain relieved by rest | No | Yes | No | | Age group affected | 60% of >45yr, 85% of >65yr | 11-70 yr, 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 | | Diagnostic imaging | Diagnostic | Diagnostic | Diagnostic (be sure clinical signs support) | #### Common Causes (Red Flags): | Potential Cause | Clinical Characteristics | |-----------------|---------------------------------------------------------------------------------------------------------------------------| | Fracture | Clinically relevant trauma in adolescent or adult. Minor trauma in elderly patient. | | Neoplasm | Ankylosing spondylitis. Pain worse at night. Unexplained weight loss. History of neoplasm. Age of more than 50 or less than 20 years.| | Infection | Constant pain, no relief with bed rest. Fever, chills, night sweats. Unexplained weight loss. History of recent systemic infection. | | Neurologic Injury | Progressive neurologic deficit. Upper and lower extremity symptoms. Bowel or bladder dysfunction. | #### Signs and Symptoms Arising from Cervical Spine Pathology | Signs | Symptoms | |-------------------------------------------|-------------------------------------------------------------------------------------------------------------| | Anesthesia (lack of sensation) | Arm and leg pain and ache. Auditory disturbance. Cough. | | Ataxia | Depressed mood. Diarrhea. Diplopia. Dizziness. | | Atrophy | Fatigue. Gait disturbance. Headache. | | Asymmetry | Insomnia. Muscle twitch. Nausea. Pain. Paresthesia. | | Drop attack | Poor balance. "Restless arms and legs." | | Dysesthesia (abnormal sensation) | Sneeze. Speech disturbance. Stiff neck. Threatened faint. Tinnitus. | | Falling | Torticollis. Vertigo. Visual disturbance. | | Fasciculation | | | Hyperesthesia (increased sensitivity) | | | Nystagmus | | | Pathologic gait | | | Reflex changes | | | Spastic gait | | | Sweating or lack of sweating | | | Tender bones | | | Tender muscles | | | Tender scalp | | | Transient loss of hearing, consciousness, sight | | | Upper extremity weakness | | - 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? - MOI - Did the symptoms come on right away? - What are the sites and boundaries of the pain? #### Differential Diagnosis of Cervical Nerve Root and Brachial Plexus Lesion | Cause | Cervical Nerve Root Lesion | Brachial Plexus Lesion | |---------------|--------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------| | | Disc herniation. Stenosis. Osteophytes. Swelling with trauma. Spondylosis. Congenital defects. | Stretching of cervical spine. Compression of cervical spine. Depression of shoulder. Thoracic outlet syndrome. | | Contributing factors | Sharp, burning in affected dermatomes. | Sharp, burning in all or most of arm dermatomes, pain in trapezius. | | Pain | | | | Paresthesia | Numbness, pins and needles in affected dermatomes. | Numbness, pins and needles in all or most arm dermatomes (more ambiguous distribution). | | Tenderness | Over affected area of posterior cervical spine. | Over affected area of brachial plexus or lateral to cervical spine. | | Range of motion | Decreased. | Decreased but usually returns rather quickly. | | Weakness | Transient paralysis usually. Myotome may be affected. Affected nerve root may be depressed. | Transient muscle weakness. Myotomes affected. May be depressed. | | Deep tendon reflexes | | | | Provocative test | Side flexion, rotation and extension with compression increase symptoms. Cervical traction decreases symptoms. Upper limb tension tests positive. | Side flexion with compression (same side) or stretch (opposite side) may increase symptoms. Upper limb tension tests may be positive.| - 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? - Nirurule out other possible conditions - Irurukout si SCI - Does the patient have any difficulty walking? Does the patient have problems with balance? - Because of cervical pain tuk at: vertigo - Does the patient experience dizziness, faintness, or seizures? - Check Table 3-12: Signs and Symptoms of Vertebrobasilar Artery Insufficiency - Does the patient exhibit or complain of any sympathetic symptoms? - Is the condition improving, worsening or staying the same? - Neurological problem? - 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? - Extension of mechanical posture problems - 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? ### Look - Search for deformities - Wryneck - Stiffness ### Observation - Head and Neck Posture - Shoulder levels - Baka mas mataas - Muscle Spasm or Any Asymmetry - Facial Expression - Boney and Soft-Tissue Contours - Evidence of Ischemia in either upper limb - Normal Sitting - Position - Raynaud’s phenomenon ### 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 #### * * * - **Anterior muscles of the neck** A diagram of an anterior view of muscles of the neck. - **Anterior muscles of the neck** A diagram of a posterior view of 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 - Extension and Right Side Bending - Right extension hypomobility, Left flexor muscle tightness, Anterior capsular adhesions, Right subluxation, Right small disc protrusion - Flexion and Right Side Bending - Left flexion hypomobility, Left extensor muscle tightness, Left posterior capsular adhesions, Left subluxation - Extension and right side bending restriction greater than extension and left side bending - Left arthrofibrosis (very hard capsular end feel), Left capsular pattern (arthritis, arthrosis) - Flexion and right side bending restriction equal to extension and left side flexion - Uncovertebral hypomobility or anomaly. ### 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 Test | Starting Position | Action | Functional Test | |--------------------|---------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------| | Supine lying | Lift head keeping chin tucked in (neck flexion) | 6 to 8 repetitions: Functional, 3 to 5 repetitions: Functionally fair, 1 to 2 repetitions: Functionally poor, 0 repetitions: Nonfunctional | | Prone lying | Lift head backward (neck extension) | Hold 20 to 25 seconds: Functional, Hold 10 to 19 seconds: Functionally fair, Hold 1 to 9 seconds: Functionally poor, Hold 0 seconds: Nonfunctional | | Side lying | Lift head sideways away from pillow (neck side flexion) (must be repeated for other side) | Hold 20 to 25 seconds: Functional, Hold 10 to 19 seconds: Functionally fair, Hold 1 to 9 seconds: Functionally poor, Hold 0 seconds: Nonfunctional | | Supine lying | Lift head off bed and rotate to one side keeping head off bed or pillow (neck rotation) (must be repeated both ways) | Hold 20 to 25 seconds: Functional, Hold 10 to 19 seconds: Functionally fair, Hold 1 to 9 seconds: Functionally poor, Hold 0 seconds: Nonfunctional | ### 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. - *alternate for gonio* ### Cervical and Thoracic Segmental Mobility - With the patient in prone, cervical and thoracic pine segmental movmenet 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 mov't 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 ~1inch 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 ### Stretching - Voluntary contraction and release methods - Muscle energy technique - Reciprocal inhibition - Post-isometric relaxation - Upper Quarter and Neck Mobilization - Traction