Clinical reasoning in assessment and treatment of cervical spine

1. Practical session in Integration of Cervical spine Assessment
and Treatment
Presented By:
Dr Ahmed Baghdadi
PhD in MSK Physical Therapy
Physiotherapy Department
Competency Validation

2. • I do not have any conflicts of interest to
declare. I do not have an affiliation (financial
or otherwise) with a pharmaceutical ,
medical device, or communications and
event planning company.

3. Objectives
By the end of this session, learners will be able to:
• Identify the correct diagnosis at least 80% of the time when
presented with perfect cases of common painful cervical
spine.
• Identify at least one history key feature and at least one
physical exam key feature for common cervical spine
diagnoses.
• Identify at least one treatment strategy key feature and at
least one technique for common cervical spine diagnoses
based on previous assessment.
• Identify how to tailor step by step treatment rational

4. Risk factors
Smoking
long history
of NP
Age
greater
than 40
female
sex
As they have all
the risk factors
plus complaining
too much
Coexisting
LBP
high job
demands

5. History
➢Safety (Red , orange, and yellow flags)
➢First Hypothesis

6. Provocation tests
• To accept, revise or reject 1st Hypothesis

7. Assessment Procedure
• Inspection
• Movement assessment
• Palpation
• Neurological assessment
• Special tests
• Physical therapy differential diagnosis ICF
classification
• Outcome measures

8. Active movement assessment
We should test for:
The amplitude of each movement.
The patient indicates whether it is painful.
Neck flexion must be considered not only as an articular test for
the cervical spine but also as a Dural test for the thoracic spine
in that it stretches both the cervical and the thoracic Dura.
Hence, if pain is elicited in the upper thoracic region, it may be
the consequence of a Dural impingement at either a cervical or
a thoracic level.

9. Passive Physiological Intervertebral Movements
PPIVM
We should Test:
Movement Quality (Restrictions and Pain)
Movement Quantity (Restrictions and Pain)
Full Articular pattern:
Great Limitation Of Extension
Equal Degree Of Limitation Of Both Rotations
Equal Degree Of Limitation Of Both Lateral Flexions
No Limitation Of Flexion.
Overpressure should be add at the end of all motions

10. Passive Accessory Intervertebral Movements
PAIVM
Use a 3 fingers contact
Articular pillar/ Spinous process/ Articular pillar
O/ A Flexion/ Extension
A/ A Rotation
C2/ C3 Sidebending, Rotation should follow
C3/ C4 Sidebending, Rotation should follow
C4/ C5 Flexion/ Extension
C5/ C6 Flexion/ Extension
C6/ C7 Flexion/ Extension
C7/ T1 Flexion/ Extension & Rotation
T1/ T4 Flexion/ Extension

11. Resisted Movements Assessment
• After active and passive tests, resisted movements are performed.
• Conduction of both rotations are sufficient.
• The other movements are only carried out in case of doubt and for
the purpose of differential diagnosis.
• test for Pain and/or weakness.
• Interpretation of positive resisted movements must be done in the
light of the overall clinical picture.
• Muscular and tendon lesions are extremely uncommon at the
cervical spine.
• The movement also gives information on motor conduction of the
first cervical nerve root.

14. 1. NP with
mobility deficits
Limited cervical ROM
• Neck pain reproduced at end ranges of active and
passive motions
• Restricted cervical and thoracic segmental mobility
• Intersegmental mobility testing reveals characteristic
restriction
Limited ROM as
capsular pattern
Full Articular
pattern
Partial Articular
Pattern
Swelling Periosteal Pain

15. NP with mobility
deficits
Acute
Pain Dominant
(Inflammatory)
Sub-acute
(Reparative)
Chronic
Resistant Dominant
(Remodeling)

16. Acute NP with mobility deficits
Thoracic
Manipulation
(level B)
Scapulothoracic and
UE strengthening
(level B)
Neck ROM exercises
(level B)
Patient Education
(level B)
cervical manipulation
(level C)

17. Sub-acute NP with mobility
deficits
Thoracic and cervical
Manipulation
(level C)
Neck and shoulder girdle
endurance exercises
(level B)
Neck and Thoracic
Mobilization
(level C)
Patient Education
(level B)

18. Chronic NP with mobility
Deficits
Multimodal Approach
Level B
Thoracic and Cervical
Manipulation and
Mobilization
stretching,
strengthening,
endurance training,
aerobic conditioning, and
cognitive affective
elements
Neuromuscular exercise
(coordination,
proprioception, and postural
training)
Patient Education and
Counseling
Dry needling, laser, or
intermittent mechanical/manual
traction

19. Mobilization
Maitland
Accessory
Physiological
Combined
Mulligan Long Lever

20. 2. NP with movement
coordination
impairment
• Neck pain with midrange
motion that worsens with
End range positions
• Point tendernessmay include
myofascial trigger points
Mechanism of onset
linked to
trauma or whiplash
• Associated (referred) shoulder
girdle or upper extremity pain
• Associated varied nonspecific
concussive signs and symptoms
• Dizziness/nausea
• Headache
Positive cranial cervical flexion
test
• Positive neck flexor muscle
endurance test
• Positive pressure algometry
• Strength and endurance
deficits
of the neck muscles

22. Acute NP with movement
coordination impairment
Patient Education
Multimodal Intervention Approach
including manual mobilization
techniques plus exercise (eg,
strengthening, endurance,
flexibility, postural, coordination,
aerobic, and functional exercises)
TENS

23. Subacute and Chronic NP with
movement coordination impairment
Cognitive Behavioral Therapy
Level B
Mobilization combined with an
individualized, progressive submaximal
exercise program including
cervicothoracic strengthening,
endurance, flexibility, and coordination
Level B

24. 3. Neck Pain With
Headache
(Cervicogenic)
Headache is precipitated or
aggravated by neck movements
or sustained positions/postures
Noncontinuous, unilateral neck
pain and associated (referred)
headache
Positive cervical flexion rotation test
Headache reproduced with
provocation of the involved upper
cervical segments
Limited cervical ROM
Restricted upper cervical
segmental mobility
Strength, endurance, and
coordination deficits of the neck
muscles

25. Acute Neck Pain With
Headache
(Cervicogenic)
Patient Education
Level B
C1-2 self-sustained
natural apophyseal glide
(self-SNAG) exercise
Level C

26. Sub-acute Neck Pain
With Headache
(Cervicogenic)
C1-2 self-SNAG
exercise
Level C
cervical manipulation
and mobilization
Level B

27. Chronic Neck Pain With
Headache
(Cervicogenic)
shoulder girdle and neck
stretching, strengthening,
and endurance exercise
Level B
cervical manipulation and
mobilization
Level B

28. 4. Neck Pain With Radiating
Pain
(Radicular)
Upper extremity dermatomal
paresthesia or numbness, and
myotomal muscle weakness
Neck pain with radiating (narrow
band pain) in the
involved extremity
Neck and neckrelated radiating pain
reproduced or relieved with radiculopathy
testing: positive test cluster includes
upperlimb nerve mobility, Spurling’s test,
cervical distraction, cervical
ROM
May have upper extremity
sensory, strength, or reflex
deficits associated with the
involved nerve roots

29. Acute Neck Pain With
Radiating Pain
(Radicular)
Patient Education and
counseling
Level C
mobilization and stabilizing
exercises, laser, and short-
term use of a cervical collar.
Level C
Direction preference
exercises
Level C

30. Chronic Neck Pain With
Radiating Pain
(Radicular)
Patient Education and
counseling
Level B
intermittent cervical traction,
combined with other
interventions such as stretching
and strengthening exercise plus
Level B
cervical and thoracic
mobilization/ manipulation.
Level B
Neural mobilization
Level C

31. THANK YOU

32. REFERENCES
1. Gross A, Forget M, St George K, et al. Patient education for neck pain.
Cochrane Database Syst Rev. 2012:CD005106.
2. Gross A, Miller J, D’Sylva J, et al. Manipulation or mobilisation for neck
pain: a Cochrane Review. Man Ther. 2010;15:315-333.
3. Gross AR, Kaplan F, Huang S, et al. Psychological care, patient
education, orthotics, ergonomics and prevention strategies for neck pain:
an systematic overview update as part of the ICON project. Open Orthop
J. 2013;7:530-561.
4. Leaver AM, Refshauge KM, Maher CG, McAuley JH. Conservative
interventions provide short-term relief for non-specific neck pain: a
systematic review. J Physiother. 2010;56:73-85.
5. Liu L, Huang QM, Liu QG, et al. Effectiveness of dry needling for
myofascial trigger points associated with neck and shoulder pain: a
systematic review and meta-analysis. Arch Phys Med Rehabil.
2015;96:944-955. https://doi.org/10.1016/j.apmr.2014.12.015