Evidence Based Evidence Based PracticePractice

Examination and Intervention Examination and Intervention for the for the

Cervical SpineCervical Spine

Condensed from Josh Hayes PT, DPT, OCSCondensed from Josh Hayes PT, DPT, OCSBy Chris Keating PT, DPTBy Chris Keating PT, DPT

ObjectivesObjectives

Review and Normalize Exam Review and Normalize Exam TechniquesTechniques

Diagnosis with Validated ToolsDiagnosis with Validated Tools CPR use to Guide TreatmentsCPR use to Guide Treatments Use the Same LingoUse the Same Lingo Greater Consistency of CareGreater Consistency of Care Practice Manual SkillsPractice Manual Skills

ExaminationExamination

AcuityAcuity Benefit from Benefit from

PT/Red FlagsPT/Red Flags Comparable SignComparable Sign Direction of Direction of

TreatmentTreatment

Canadian C-Spine Canadian C-Spine RuleRule

Neck Disability Neck Disability IndexIndex

Clinical Significance >10%Clinical Significance >10%– 0-8% No Disability0-8% No Disability– 10-28% Mild10-28% Mild– 30-48% Moderate30-48% Moderate– 50-68% Severe50-68% Severe– 70-100% Complete70-100% Complete

ExaminationExamination

Cervical MyelopathyCervical Myelopathy– B&B, Atrophy and GaitB&B, Atrophy and Gait

Neoplastic ConditionsNeoplastic Conditions– >50yo , Constant Pain and Night pain>50yo , Constant Pain and Night pain

Upper Cervical Ligamentous InstabilityUpper Cervical Ligamentous Instability– Limited AROM (CROM/Inclinometer), Occipital HA and CM Limited AROM (CROM/Inclinometer), Occipital HA and CM

SignsSigns

VA InsufficiencyVA Insufficiency– D’s (Dysphasia, Dysarthria and Diplopia)D’s (Dysphasia, Dysarthria and Diplopia)

Inflammatory or Systemic DiseaseInflammatory or Systemic Disease– Temp > 37, Resting Pulse >100, Resp Rate >25 and Temp > 37, Resting Pulse >100, Resp Rate >25 and

FatigueFatigue

Special TestsSpecial Tests

ULNTTULNTT Spurling’sSpurling’s DistractionDistraction VAVA Sharp PurserSharp Purser

– Transverse LigamentTransverse Ligament Alar Ligament TestAlar Ligament Test

DiagnosisDiagnosis

MobilityMobility CentralizationCentralization ConditioningConditioning Pain Control (poor candidate)Pain Control (poor candidate) HeadacheHeadache

1 - Mobility1 - Mobility

< 3 Months< 3 Months No Radicular/Referred Symptoms in No Radicular/Referred Symptoms in

UQUQ Limited Lateral Flexion and RotationLimited Lateral Flexion and Rotation No Nerve Root CompressionNo Nerve Root Compression

Rx: C-s and T-s Mobs/Manips and Rx: C-s and T-s Mobs/Manips and AROMAROM

2 - Centralization2 - Centralization

UQ SymptomsUQ Symptoms Peripheralization or CentralizationPeripheralization or Centralization Nerve Root CompressionNerve Root Compression

Rx: Traction, Repeated Motion in Rx: Traction, Repeated Motion in Directional PreferenceDirectional Preference

3 - Conditioning3 - Conditioning

Low Pain and NDILow Pain and NDI > 3 Months> 3 Months No Nerve Root CompressionNo Nerve Root Compression No Directional PreferenceNo Directional Preference

Rx: Strengthening or Deep and Rx: Strengthening or Deep and Global Stabilizers throughout UQGlobal Stabilizers throughout UQ

4 - Pain Control4 - Pain Control

High Pain and NDIHigh Pain and NDI Very Recent OnsetVery Recent Onset TraumaTrauma Radiating UQ painRadiating UQ pain Very Poor Tolerance to Exam and RxVery Poor Tolerance to Exam and Rx

Rx: Gentle AROM, Modalities and Rx: Gentle AROM, Modalities and Activity ModificationActivity Modification

5 - Headache5 - Headache

HA Preceded by Neck PainHA Preceded by Neck Pain HA Triggered with Neck MovementHA Triggered with Neck Movement HA Elicited by Posterior PressureHA Elicited by Posterior Pressure

Rx: C-s manips/mobs, Rx: C-s manips/mobs, Strengthening and PostureStrengthening and Posture

Cervical RadiculopathyCervical Radiculopathy

ULTTAULTTA Involved Rotation < 60Involved Rotation < 60°° DistractionDistraction Spurling’sSpurling’s

3+ 6.1 LR3+ 6.1 LR 4+ 30.3 LR 4+ 30.3 LR

Cervical RadiculopathyCervical Radiculopathy

Predictors of SuccessPredictors of Success– < 54 yo< 54 yo– Non-Dominent ExtermityNon-Dominent Extermity– Looking Down Doesn’t Worsen Looking Down Doesn’t Worsen

SymptomsSymptoms– Manual Therapy, Traction and Flexor Manual Therapy, Traction and Flexor

StrengtheningStrengthening

Manual Therapy & ExercisesManual Therapy & Exercises

Downglide Mob/ManipDownglide Mob/Manip Upglide Mob/ManipUpglide Mob/Manip Cervical Lateral Glide in ND PositionCervical Lateral Glide in ND Position Supine DOGSupine DOG Thoracic ScrewThoracic Screw Extension ProgressionExtension Progression See Handout for ExercisesSee Handout for Exercises

Questions?Questions?

ReferencesReferences

Proposal of a Classification System Proposal of a Classification System for Patients with Neck Pain. Childs et for Patients with Neck Pain. Childs et al, JOSPT 34:11 2004al, JOSPT 34:11 2004

Predictors of Short-Term Outcome in Predictors of Short-Term Outcome in People With a Clinical Diagnosis of People With a Clinical Diagnosis of Cervical Radiculopathy. Cleland et al, Cervical Radiculopathy. Cleland et al, PTJ 87:12PTJ 87:12