intro, cases, cervical anatomy 15.ppt - continuing ed cases, cervical anatomy 15...in trauma groups...
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Pre-Course Review
Jason Zafereo, PT, OCS, FAAOMPTCli i l O th di R h bilit ti Ed tiClinical Orthopedic Rehabilitation Education
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Objectives
Review key concepts from history-taking, examination, and treatment self-studies
Apply a hypothesis-testing framework to pp y yp gcritically reason through orthopedic patient casesp
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History-taking
Data collection and hypothesis f tiformation
Subjective exam– History of present illness
Onset, Location, Nature, Aggravating/easing, Intensity, Associated symptoms, Timing
– Functional statusMedical History– Medical History Co-morbidities, radiology, prior
treatment, patient goal(s)3
Examination and Treatment
Hypothesis testing during bj ti d t t tobjective exam and treatment
Objective exam– Impairment: ROM, Palpation for
position, Flexibility, MMT– Pathology: ROM Palpation for– Pathology: ROM, Palpation for
condition, Neurological exam, Special testing, Resisted testing
Treatment– Pain, Stiffness, Weakness 4
Critical Reasoning
Hypothesis categories– Pathology
Contractile/non-contractile
Contributing factors– Contributing factors Environmental, Behavioral, Emotional, Physical,
Biomechanical
– Contraindications/precautions– Prognosis
Co-morbidities Flags Healing phase Exam findings Co-morbidities, Flags, Healing phase, Exam findings
– Management Yellow flags, Pain, Stiffness, Weakness, Education5
Case Practice
Read the information immediately under
Narrow your hypothesis list and make a list of the ~3 confirming
SUBJECTIVE for Case 4 List 2-3 pre-history pathology
hypotheses and ~5 subjective
tests you would like to see in your exam for each
Read the exam and attempt to findings you would expect to have for each
Read the history and attempt
“make the features fit” Change hypotheses as needed Finally, list your post-exam
to “make the features fit” your hypotheses
a y, st you post e ahypotheses for pathology, biomechanical contributing factors, contraindications/precautions, prognosis, and management
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Cervical Spine Applied Anatomy
Jason Zafereo, PT, OCS, FAAOMPTCli i l O th di R h bilit ti Ed tiClinical Orthopedic Rehabilitation Education
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Objectives
Apply key concepts from the cervical anatomy/kinesiology self-study to aid in differential diagnosis for the following:– Headache – Cervical radiculopathy/myelopathy– Cervical disc and joint disorders– Cervical “instability”y
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HEADACHE
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M l k l l i f dMusculoskeletal pain referred to TCN from structures innervated by the C1-3 spinal nerves y p
• Upper cervical synovial joints (esp. C2-3)
• Upper cervical muscles• C2-3 disc• Dura mater of upper SC and
posterior cranial fossaP i i h i d i hibi dPain either perceived or inhibited based on higher center activity
• Cortex• Brainstem
10Boyling et al., Grieve's Modern Manual Therapy: The Vertebral Column, 2005; Bogduk, N Curr Pain Headache Rep, 2001
Differential Diagnosis of Headache (IHS)
Primary HeadachesTension t pe
Secondary H d h– Tension-type
– Migraine– Cluster
E ti l
Headaches– Trauma– Vascular
– Exertional
Other Headaches– Neuralgias
Vascular– Intracranial– Substance/Withdrawal
I f tig– Central Facial Pain
– Infection– Homeostasis– Cervical/Cranial– Psychiatric
11Mixed headache types are common with sensitization of TCN!!
Migraine Headache (IHS)
Headache attacks lasting 4-72 hours (untreated or unsuccessfully
Aura consisting of at least one of the following, but no motor ( y
treated) Headache has at least two of the
following characteristics:
gweakness:
– fully reversible visual symptoms including positive features (eg, flickering lights spots or lines)
– unilateral location– pulsating quality– moderate or severe pain intensity
aggravation by or causing
flickering lights, spots or lines) and/or negative features (ie, loss of vision)
– fully reversible sensory symptoms including positive features (ie pins– aggravation by or causing
avoidance of routine physical activity
During headache at least one of the
including positive features (ie, pins and needles) and/or negative features (ie, numbness)
– fully reversible dysphasic speech di t bfollowing:
– nausea and/or vomiting – photophobia and phonophobia
disturbance
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Cluster Headache (IHS)
Severe or very severe unilateral orbital, supraorbital and/or
Attacks have a frequency from one every other day to 8 per day p
temporal pain lasting 15-180 minutes if untreated
Headache is accompanied by at l t f th f ll i
y y p y
least one of the following: – ipsilateral conjunctival injection
and/or lacrimation – ipsilateral nasal congestion p g
and/or rhinorrhea – ipsilateral eyelid edema – ipsilateral forehead and facial
sweatingsweating – ipsilateral miosis and/or ptosis – a sense of restlessness or
agitation 13
Occipital Neuralgia (IHS)
Paroxysmal stabbing pain, with or without persistentwith or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third goccipital nerves
Tenderness over the affected nerve
Pain is eased temporarily by local anesthetic block of the nerve
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Dx Secondary HeadachesDx Secondary HeadachesMert et al, J Headache Pain 2008
‘‘Red flags’’ for secondary disordersS dd t f h d h– Sudden onset of headache
– New onset of headache with aura– Onset of headache after 50 years of age– Increased frequency or severity of headache– New onset of headache with an underlying medical condition– Headache with concomitant systemic illnessHeadache with concomitant systemic illness
Patients presenting to ER with headache– Presence of comorbidity– Patient’s age > 50– Existence of trigger factor– * 9.3 fold increased risk of secondary HA15
RADICULOPATHY/MYELOPATHY/
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Differential Diagnosis
Tension event associated withassociated with herniated intervertebral disc
Compression event Compression event associated with degenerative disc changeschanges
– Zygapophyseal joint– Uncovertebral joint– Ligamentum flavum
Sizer et al, Pain Practice, 200117
Soft Herniation
Degeneration occurs from the inside to outside (similar to (lumbar discs)
Most common C5/6 – C7/T1 Irritated posterior longitudinal
ligament leads to neck and arm pain
Acute torticollis positional faultP i ith itt l l Pain with sagittal plane movements
Treatment focused on axial decompressiondecompression
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Hard Herniation
Degeneration occurs from the outside to insideoutside to inside
Most common C2/3 – C4/5– Smallest A/P diameter and
highest uncinate processes C4-6 (Ebraheim et al, Clin Orthop Rel Res, 1997)
IVF stenosis creates isolated arm painPain with foraminal closing Pain with foraminal closing
Treatment focused on A/P decompression19
LOCAL CERVICAL SPINE PAIN: DISC VS JOINT
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Directional Preference vs Directional Preference vs Centralization
Centralization (CEN)M t f di t d
Prevalence in neck pain4 (CEN) 7 (DP)– Movement of radiated
pain towards the midline of the spine. Pain may actually increase at the
– .4 (CEN); .7 (DP)– Young and fewer
comorbidities more likely CENactually increase at the
spine.
Directional preference (DP)
CEN– DP associated with acute
sx and greater i t i f ti l(DP)
– Decrease in symptom intensity, CEN, or
improvement in functional outcome
– Neither CEN nor DP associated ith painimprovement in ROM
associated with a movement.
associated with pain outcomes
Edmond et al, 201421
Centralization (CEN)
McKenzie theory of CEN (Stevens and McKenzie(Stevens and McKenzie 1988)
– Alteration of gelatinous nucleus position through loading of IVD
– Requires intact annulus
Alternate mechanism for effectiveness in cervical spine possiblyspine, possibly neurophysiological (Mercer and Jull 1996)22
Differential Diagnosis
Soft disc herniationPositive dural tension testing– Positive dural tension testing
Degenerative disc disease– Reduced cervical lordosis
P i ith 3 D ti t ti l d– Pain with 3-D motion testing uncoupled Joint
– Pain with 3-D motion testing coupled– Zygapophyseal
Primary restriction into rotation– Uncovertebral
Primary restriction into sidebending
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INSTABILITY
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Pathophysiology
Degeneration and mechanical injury causesmechanical injury causes (Panjabi, J Spinal Disord, 1992)
– Poor postureR titi ti l t– Repetitive occupational trauma
– Acute trauma– Weakness of cervical
musculaturemusculature
Increase in neutral zone of a spinal segment
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Pathophysiology
Healthy versus microtrauma versusmicrotrauma versus macrotrauma (Jull et al 2004)
E i SCM ti ti– Excessive SCM activation in trauma groups during Craniocervical flexion
Chronic neck pain (Falla 2004)
– Decreased deep neck flexor activation with SCM overactivation
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Cervicothoracic Musculature
Global musclesUpper trapezius/Levator– Upper trapezius/Levator
– Splenius capitis/cervicis– Semispinalis capitis
SCM– SCM– Scalenes
Local muscles– Semispinalis cervicis– Multifidus– Longus colli/capitis (deep– Longus colli/capitis (deep
neck flexors)
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Differential Diagnosis
Directional Susceptibility to Movement (DSM)Movement (DSM)– Uni-planar motion
Extension Flexion Rotation
Combined motion– Combined motion Extension-Rotation
– Most common syndrome (Sahrmann 2011)(Sahrmann 2011)
Flexion-Rotation28
Extension DSM
History of whiplashOld ti t Older patient
Forward head/Increased thoracic kyphosiskyphosis
Pain/Hinge point with cervical extension
Weak DNF/Thoracic extensors Stiffness thoracic extension, SCM,
scalenescalene
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Flexion DSM
Exaggerated “correct” posture Younger patient Flat thoracic spine Pain with cervical flexion Weak intrinsic neck extensors Stiffness DNF and thoracic
flexion
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Rotation DSMSahrmann 2002
Scapula determines asymmetrical rotation forces on neckrotation forces on neck
– Levator rotates neck ipsilateral – Upper trap rotates neck
contralateral Pain/clicking during
rotation/sidebend Most common scapular impairment Most common scapular impairment
– Scapular downward rotation – Scapular depression– Tight: Levator Rhomboid Pec– Tight: Levator, Rhomboid, Pec
minor, Lats– Weak: Serratus, Lower trap,
*Upper trap31