lesson 7 mid cervical spine assessment and treatment
TRANSCRIPT
Lesson 7
Mid Cervical Spine
Assessment and Treatment
Arthrokinematics
Sidebend /rotation
U joints/ Z jts
ipsi inf, med, post
( IMP)
contra sup,ant, lat
( SAL)
Rotation / Side Bend
Segment ROM
Mean Range
C3-4 6.5 3-10
C4-5 6.8 2-12
C5-6 6.9 0-12
C6-7 2.1 2-10
C7-T1 2.1 -2-7
Mean Values and ranges of axial rotation of cervical motion segments CT scanning Penning , Wilmink 87
Normal ROM in axial rotation and coupled motion – biplanar radiography Mimura’89
Segment Axial rotation SD
Flex/ext
SD
Lateral flexion SD
C3-4 6 ( 5) -3( 5) 6( 7)
C4-5 4 (6) -2( 4) 6( 7)
C5-6 5( 4) 2(3) 4( 8)
C6-7 6(3) 3( 3) 3( 7)
Objective Assessment
• Active ROM – upper vs mid cervical
• Repeated Movement
• Habitual and Combined Movements
Joint Play Movements
• Central PA C3-7 – what does it tell you?
• Central Angle Caudally – what movement ?
• Unilateral PA 3-7 – incline cranially and caudally
Passive Segmental Tests
PPIVMS• Used to determine the amount and quality of
passive physiological movement available at a motion segment
• Flexion, Extension, Side bending/rotation
( unilateral flexion and extension)
Segmental Compliance Test
• Assess the connective tissue compliance of the arthrokinematic motions ( rocks and slides) associated with various physiological movements of the segment
• Clinician is attempting to appreciate the quality of the “ give” present in the CT when the segment is at R2
NDI Measurement Properties
Coefficients• Internal consistency =.87
• Test-retest reliability (several days) .89 to .94
• Correlates with SF-36 Physical Component Score r=.53; Pain intensity r=.56; Patient Specific Functional Scale (PSFS) score r=.80
NDI Measurement Properties
Scale Points• Variation in a single score value ±3 (90% CI)
• Minimal detectable change 5 points
• Minimal clinically important difference 5 points
Neck Disability Index (NDI)(Vernon & Mior 1991)
10 item self-report functional status measure
Items scored on a 6 point scale (0 to 5)
Total score value 0 (high function) to 50 (low)
About 3 to 5 minutes for patient to complete
20 seconds to score without computational aids
Objective Assessment
Segmental Integrity Tests
• Evaluate the ability of motion segment’s passive elements to resist uni-planar forces
• Test passive subsystem ( ligaments of knee)
NZ / EZ Relationship
Boundary between R 1 and R2
NZ
EZ
Stability Tests
Treatment
• Mobilization – traction, IMP
• Exercise
• Education
Tractionneutral and restriction
Strategies for Stabilization
Instability• Loss of the ability of the spine to maintain
relationships between vertebrae in such away to prevent:
» spinal cord or nerve root damage» incapacitating deformity» severe pain (Panjabi, 1990)
• Often defined as an increase in a particularmeasure (eg: ADI>3mm)
Neutral Zone (Panjabi, 1989)
• That part of the ROM
which requires very little force to produce minimal resistance to the movement
Stability
Control
system
Passive
system
Active system
Panjabi 1992
Psycho Social
Efficient Movement = Optimal Stabilization
Requirements
Intact bones, joints, ligaments
Efficient and coordinated muscle action
Appropriate neural responses
Learning to control the Deep and Postural muscles
Edgepac Queensland Aust ‘99
Scapular muscle control
Poor postural position of the scapula
Balanced force couple around the scapula
Muscle impairments of the axioscapular muscles
• Loss of holding capacity in any of the upper, mid, + lower portions of trapezius
• Loss of holding capacity of serratus anterior
Imbalance of large posterior muscles and deep anterior muscles
Muscles impairments in cervical pain syndromes
• Poor activation and holding capacity of deep neck flexors
• Overactivity of the superficial muscles that span cervical spine
Deep
stabilizing
muscles of the
neck
SCMSCM
Muscle impairments of the axioscapular muscles
• Overactivity of levator scapulae, pectoralis major or minor , scalenes
• Overactivity of upper traps in response to sensitive neural tissues
Stabilizing Muscles of the Scapula
Cervical Pain syndromes
• Superficial muscles attempt to stabilize the neck but anatomically not designed for segmental support
• Decreased capacity for co contraction of deep neck flexors and extensors to increase segmental stiffness
Cervical Pain Syndromes
• Poor pattern of superficial and deep neck flexor synergy in sagittal plane movements
• Often poor postural position of neck and girdles
• Tightness suboccipital extensors
Suboccipitals become tight
Stretching often contraindicated
Neural tissue must be respected
Head and neck in mid range neutral position, face parallel to the ceiling. May add towels
Avoid craniovertebral extension
Stabilizer is placed behind the neck suboccipitally
Stabilizer is inflated to fill the suboccipital space (approx 20mmHG)
Longus colli activation
Motor Control is NOT a birthright
Treatment Advice
• No phasic ,erratic movement
• Emphasis on precision and control
• Discourage activity of superficial neck
flexors
Treatment Advice
• Train joint position sense
• Perform exercises at least twice a day
• Exercise must be pain free
• Deep muscle function does not return automatically
Components of an Effective Exercise Program
• Cardiovascular Endurance
• Muscle strength, endurance and co-ordination
• Flexibility
• Body Composition
Motor Learning
• Formal motor skill training
• Perception of the specific contraction
• Understand the task, what it feels like, instructions, visual cues, different postures/positions, various facilitation and feedback
• Enhance the patients perception of the deep muscle motor skill
• Focus on one particular muscle at a time
Motor Learning
Associative Stage Automatic Stage • “Got the idea” practice thousands of repetitions
• Care with fatigue
Motor LearningExercise Progression • Commence co-activation of TA/multifidus
• Combine with short neck flexors
• Increase holding time
• Increase number of contractions
• Reduce feedback
• Add diaphragmatic breathing (abdominal wall movement while maintaining a deep muscle contraction) Intermediate steps to encourage air flow: counting, talking