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  1. 1. Cervical Spine Examination and Intervention Daemen College DPT Program
  2. 2. Objectives <ul><li>Review the anatomy, biomechanics, and arthrokinematics of the cervical spine. </li></ul><ul><li>Introduce a sequence of examination tests and measures designed to arrive at a patient classification for cervical spine disorders. </li></ul><ul><li>Analyze patient responses to repeated end range cervical motions to determine appropriateness of exercises based on direction of preference. </li></ul><ul><li>Evaluate the cervical spine to determine the presence of hypermobility and instability. </li></ul><ul><li>Apply appropriate exercise and manual physical therapy interventions designed to improve cervical spine mobility, stability, and function </li></ul>
  3. 3. Cervical Spine Examination <ul><li>History/Subjective </li></ul><ul><li>Structural </li></ul><ul><li>AROM </li></ul><ul><li>Repeated movements </li></ul><ul><li>PROM (PIVM) </li></ul><ul><li>Muscle performance – deep neck flexor strength and endurance, muscle balance tests </li></ul><ul><li>Neurological – dermatomes, myotomes, muscle stretch reflexes, neurodynamic testing </li></ul><ul><li>Palpation </li></ul><ul><li>Special tests </li></ul>
  4. 4. Subjective Examination <ul><li>Area </li></ul><ul><li>Nature </li></ul><ul><li>Behavior </li></ul><ul><li>Mechanism of injury </li></ul><ul><li>Duration </li></ul><ul><li>Review of systems </li></ul><ul><li>Functional limitations/perceived level of function </li></ul>
  5. 5. Neck Disability Index <ul><li>Vernon H, Mior S. </li></ul><ul><li>A modification of the Oswestry Low Back Pain Index </li></ul><ul><li>Test-retest reliability was conducted on an initial sample of 17 consecutive whiplash patients (r=0.89, p,>05) </li></ul><ul><li>Concurrent validity was established through comparing NDI scores with McGill Pain Questionnaire (correlations 0.69-0.70) </li></ul>
  6. 6. Differential Diagnosis <ul><li>What is the first order classification? </li></ul><ul><li>Is the patient’s condition warrant referral to another medical professional? </li></ul><ul><li>What further tests/measures are indicated? </li></ul>
  7. 7. Medical Diagnosis Examples <ul><li>ICD – 9 – CM </li></ul><ul><ul><li>724 – unspecified disorder of the back </li></ul></ul><ul><ul><li>839.0 – dislocation, cervical (closed) </li></ul></ul><ul><ul><li>847 – sprains and strains of parts of the back </li></ul></ul>
  8. 8. Associated with Spinal Disorders – Pattern 4F 
  9. 9. Connective Tissue Dysfunction – Pattern 4D
  10. 10. Structural Examination <ul><li>Detailed examination of alignment and structure from anterior, posterior, lateral views </li></ul><ul><li>Head tilt, torticollis </li></ul><ul><li>Examination of sitting posture </li></ul><ul><li>Correlation of symmetry to back pain –Levangie PK. The association between static pelvic asymmetry and low back pain. </li></ul><ul><li>Spine. 2000;2551-2552. </li></ul>
  11. 11. AROM <ul><li>Quality and quantity of movement through goniometric measures and observation of quality of movement </li></ul><ul><li>Flexion </li></ul><ul><li>Extension </li></ul><ul><li>Sidebending </li></ul><ul><li>Rotation </li></ul>
  12. 12. Cervical Spine Repeated Movements <ul><li>Protraction </li></ul><ul><li>Retraction </li></ul><ul><li>Retraction with extension </li></ul><ul><li>Above testing in weightbearing </li></ul><ul><li>Baseline prior to each test movement </li></ul><ul><li>PDM or ERP </li></ul><ul><li>Deviations </li></ul><ul><li>Retraction </li></ul><ul><li>Retraction with extension </li></ul><ul><li>Above testing in supine </li></ul><ul><li>Baseline prior to each test movement </li></ul><ul><li>PDM or ERP </li></ul><ul><li>Deviations </li></ul><ul><li>Repeated sidebending and repeated rotation tested in sitting if no effect from saggital plane movements </li></ul>
  13. 13. Assessment of patient responses to repeated movements <ul><li>Increased </li></ul><ul><li>Decreased </li></ul><ul><li>Increased/no worse </li></ul><ul><li>Decreased/no better </li></ul><ul><li>Centralized </li></ul><ul><li>Peripheralized </li></ul><ul><li>Worse </li></ul><ul><li>Better </li></ul><ul><li>No effect </li></ul>
  14. 14. Neck Retractions, Cervical Root Decompression, and Radicular Pain <ul><li>Abdulwahab SS, Sabbahi M. JOSPT . 2000;30:4-12. </li></ul><ul><li>Neck retractions appeared to alter H reflex amplitude. These exercises may promote cervical root decompression and reduce radicular pain in patients with C7 radiculopathy </li></ul>
  15. 15. Reliability of McKenzie Classification of Patients with Cervical or Lumbar Pain <ul><li>Clare HA, Adams R, Maher CG, J. </li></ul><ul><li>Manipulative Physiol Ther . 2005; 28:122-127. </li></ul><ul><li>The reliability for syndrome classification was k=0.84 with 96% agreement for the total patient pool, and k=0.63 with 92% agreement for cervical patients. </li></ul><ul><li>The reliability for subsyndrome classification was k=0.87 with 90% agreement for the total patient pool, and k=0.84 with 88% agreement for the cervical patients </li></ul>
  16. 16. PROM <ul><li>Assessment of end feel (may avoid end range rotation in certain patients) </li></ul><ul><li>Flexion </li></ul><ul><li>Extension </li></ul><ul><li>Sidebending </li></ul><ul><li>Rotation </li></ul><ul><li>What are the normal end feels for the cervical spine? </li></ul><ul><li>What tissues are placed on stretch with assessment of the end feel? </li></ul><ul><li>Are other passive tests indicated? </li></ul>
  17. 17. Passive intervertebral motion testing (PIVM) <ul><li>Also referred to as single segmental mobility testing (SSMT) </li></ul><ul><li>Flexion, extension, sidebending, rotation in weightbearing and nonweightbearing positions </li></ul><ul><li>Palpation between or lateral to spinous processes </li></ul><ul><li>Poor to moderate kappa coefficients – cervical (Fjellner et al., 1999, Smedmark, Wallin, Arvidsson, 2000). </li></ul>
  18. 18. Lateral mobility, A-P, and P-A Tests <ul><li>Lateral mobility also referred to as position testing </li></ul><ul><li>Lateral translation (sidegliding) in neutral, flexion, extension </li></ul><ul><li>A-P segmental mobility </li></ul><ul><li>P-A segmental springing from prone </li></ul>
  19. 19. Muscle Performance <ul><li>Isometric resistive testing </li></ul><ul><li>Specific Manual muscle tests </li></ul><ul><li>Muscle performance – strength and endurance of the deep neck flexors </li></ul>
  20. 20. Neurological testing <ul><li>Dermatomes </li></ul><ul><li>Myotomes </li></ul><ul><li>Muscle stretch reflexes </li></ul><ul><li>Tests for Adverse neural tension </li></ul>
  21. 21. Adverse neural tension testing <ul><li>Upper limb tension tests (ULTT) – median, radial, ulnar </li></ul><ul><li>Brachial plexus tension test </li></ul><ul><li>Elvey test </li></ul>
  22. 22. Neurodynamic testing <ul><li>Based on adverse neural tension test </li></ul><ul><li>(Brachial plexus stretch, Elvey’s) </li></ul><ul><li>Assess upper cervical flexion mobility for range and reproduction of symptoms </li></ul><ul><li>Return to cervical neutral and place patient in Elvey’s position </li></ul><ul><li>Reposition patient in upper cervical flexion and observe response. </li></ul>
  23. 23. Special tests <ul><li>Compression </li></ul><ul><li>Foraminal compression </li></ul><ul><li>Distraction </li></ul><ul><li>Vertebral artery </li></ul><ul><li>Quadrant test </li></ul><ul><li>Tests for space occupying lesion </li></ul><ul><li>Valsalva, DeJorines Triad (coughing, sneezing, straining) </li></ul>
  24. 24. Palpation <ul><li>Tissue texture abnormalities </li></ul><ul><li>Skin rolling </li></ul><ul><li>Skin puckering </li></ul><ul><li>Tone </li></ul><ul><li>Ligamentous tenderness </li></ul><ul><li>Positional faults, symmetry </li></ul>
  25. 25. Palpation <ul><li>Articular pillars </li></ul><ul><li>Spinous processes </li></ul><ul><li>Transverse processes </li></ul><ul><li>External occipital protuberance </li></ul><ul><li>Soft tissue tone </li></ul>
  26. 26. Assessment/Diagnosis <ul><li>Positive findings with repeated movements may indicate derangement </li></ul><ul><li>Positive findings with passive movements may indicate joint </li></ul><ul><li>Positive findings with resistive movements may indicate a muscle lesion </li></ul>
  27. 27. PT Diagnosis <ul><li>Musculoskeletal practice pattern? </li></ul><ul><li>Acute/subacute/ chronic? </li></ul><ul><li>Postural </li></ul><ul><li>Dysfunction </li></ul><ul><li>Hypomobility </li></ul><ul><li>Soft tissue dysfunction </li></ul><ul><li>Hypermobility </li></ul><ul><li>Derangement (centralizers vs. noncentralizers </li></ul><ul><li>Anterior </li></ul><ul><li>Posterior </li></ul><ul><li>Posterolateral </li></ul><ul><li>Far lateral </li></ul><ul><li>Muscle length/ strength </li></ul><ul><li>Myofascial </li></ul>
  28. 28. Classification <ul><li>Postural </li></ul><ul><li>Derangement </li></ul><ul><li>Dysfunction </li></ul><ul><li>Joint dysfunction </li></ul><ul><li>Muscle lesion </li></ul><ul><li>Ligamentous sprain </li></ul><ul><li>Hypermobility/instability </li></ul>
  29. 29. Cervical Derangements <ul><li>#s 1-6 are posterior </li></ul><ul><li>#s 1,3,5 no deformity </li></ul><ul><li>#s 1,2 central/symm </li></ul><ul><li>#s 2,4,6 deformity </li></ul><ul><li>#2 – acute kyphosis </li></ul><ul><li>#4 – torticollis </li></ul><ul><li>#6 - torticollis </li></ul><ul><li>#5,6 pain below elbow </li></ul><ul><li>Goal is to get patient to perform retraction in sitting throughout day </li></ul><ul><li>May need to utilize </li></ul><ul><li>nonweighting retraction and extension, sidebending, rotation </li></ul>
  30. 30. Treatment of derangement <ul><li>Postural correction </li></ul><ul><li>Exercises in direction of preference </li></ul><ul><li>May begin in weightbearing or non-weightbearing position </li></ul><ul><li>Recovery of function </li></ul>
  31. 31. PT Intervention <ul><li>Intervention directed toward patient classification </li></ul><ul><li>Postural syndrome – postural correction </li></ul><ul><li>Derangement – exercises according to direction of preference </li></ul><ul><li>Dysfunction – passive stretching, soft tissue mobilization </li></ul><ul><li>Adverse neural tension - neuromobilization </li></ul><ul><li>Hypomobility - manual physical therapy </li></ul><ul><li>Hypermobility – cervicial spine stabilization </li></ul><ul><li>Muscle lesion – muscle re-education, therapeutic exercise </li></ul><ul><li>Manual or mechanical traction </li></ul>
  32. 32. Manual Physical Therapy <ul><li>Risk vs. Benefit in cervical spine (Rivett, DiFabio) </li></ul><ul><li>Progression of patient generated forces (McKenzie) </li></ul><ul><li>Grades of mobilization I-IV (Maitland) </li></ul><ul><li>PACVP </li></ul><ul><li>PAVP </li></ul><ul><li>TVP </li></ul><ul><li>High velocity thrust </li></ul><ul><li>Safe practice through Premanipulative testing, Grades of mobilization, Positioning (Meadows), Component technique (Hartman) </li></ul>
  33. 33. Upper Cervical Spine Examination <ul><li>Subjective </li></ul><ul><li>Functional questionnaire – Neck Disability Index (NDI) </li></ul><ul><li>Gait analysis </li></ul><ul><li>Structural exam </li></ul><ul><li>AROM - midcervical </li></ul><ul><li>quality of motion </li></ul><ul><li>quantity of motion </li></ul><ul><li>Repeated movements – midcervical </li></ul><ul><li>If no effect: </li></ul><ul><li>AROM – upper cervical </li></ul><ul><li>Passive intervertebral motion – upper cervical </li></ul><ul><li>Motor performance </li></ul><ul><li>Neurological </li></ul><ul><li>Palpation </li></ul>
  34. 34. Examination of upper cervical spine <ul><li>Presence of upper cervical pain, headaches, trauma </li></ul><ul><li>Failure to respond to cervical spine examination </li></ul><ul><li>Association with TMD </li></ul>
  35. 35. Cervical and Vertebrobasilar Tests <ul><li>Special tests or tests administered early in the examination? </li></ul><ul><li>Vertebral artery tests </li></ul><ul><li>Sitting, supine, prone </li></ul><ul><li>Rotatory nystagmus test </li></ul><ul><li>Cervical spine stability tests </li></ul><ul><li>Alar ligament </li></ul><ul><li>Sharp-Purser </li></ul><ul><li>Transverse ligament test </li></ul><ul><li>Aspinall </li></ul><ul><li>Sensitivity/specificity </li></ul><ul><li>Screening tools for manual therapy </li></ul>
  36. 36. <ul><li>Special Tests </li></ul><ul><ul><li>Ligamentous Testing </li></ul></ul><ul><ul><ul><li>Vertebral artery test </li></ul></ul></ul><ul><ul><ul><li>Compression </li></ul></ul></ul><ul><ul><ul><li>Distraction </li></ul></ul></ul><ul><ul><ul><li>Foraminal closure </li></ul></ul></ul><ul><ul><ul><li>Alar ligament test </li></ul></ul></ul><ul><ul><ul><li>Transverse ligament test </li></ul></ul></ul><ul><ul><ul><li>Aspinall’s test </li></ul></ul></ul><ul><ul><ul><li>Odontoid fracture test </li></ul></ul></ul><ul><ul><ul><li>Sharp-Purser test </li></ul></ul></ul>Are provocation tests indicated?
  37. 38. Questions Regarding Cervical Spine Stability and Vertebrobasilar Tests <ul><li>Applied as precautionary measures prior to movement tests or prior to manual physical therapy intervention? </li></ul><ul><li>Sensitivity/specificity? </li></ul><ul><li>Are provocation tests safe? </li></ul>
  38. 39. Examination - AROM The axis for upper cervical flexion and extension with with mid-cervical spine rotated. The axis for upper cervical rotation with mid-cervical spine flexed. The axis for upper cervical sidebending
  39. 40. Upper Cervical Biomechanics <ul><li>Upper cervical flexion measures 10-15 degrees </li></ul><ul><li>Upper cervical extension measures 20-25 degrees </li></ul><ul><li>Upper cervical sidebending measures 5 degrees </li></ul><ul><li>Upper cervical rotation measures 40-45 degrees </li></ul>
  40. 41. Examination - PROM Assessing upper cervical passive flexion and extension Assessing upper cervical sidebending Assessing C1-C2 rotation
  41. 42. Examination Rotatory Nystagmus Test Distinguishing vertebral artery from vestibular involvement (Patient rotates trunk right while head remains stationary)
  42. 43. Assessment of deep neck flexors <ul><li>Strength: Cranio-cervical flexion test </li></ul><ul><li>Pressure biofeedback unit inflated to 20 mm, testing at initial pressure of 22 mm held for 10 seconds (Jull et. al., 2000). </li></ul><ul><li>Endurance: Chin retraction and elevation of head </li></ul><ul><li>Head held 1 inch above the plinth, line drawn across one of neck folds, PT supports occiput </li></ul><ul><li>(Krout and Anderson, 1966, Childs et. al., 2003) </li></ul>
  43. 44. Initiation of Guidelines <ul><li>Hypomobility vs. Hypermobility </li></ul><ul><li>Vestibular component of treatment </li></ul><ul><li>Cervical component of treatment </li></ul><ul><li>Initiation of standardized outcomes </li></ul><ul><li>Evidence-based </li></ul><ul><li>Retrospective analysis </li></ul>
  44. 45. Anticipated Goals/Expected Outcomes <ul><li>Need for outside referral </li></ul><ul><li>Hypomobility vs. hypermobility </li></ul><ul><li>Lengthening vs. strengthening </li></ul><ul><li>Integrated approach based on patient exam </li></ul>
  45. 46. Cervical Spine Intervention <ul><li>Posture </li></ul><ul><li>Patient self-treatment, therapeutic exercise: stability, mobility, both </li></ul><ul><li>Manual therapy: mobilization, manipulation, muscle energy technique </li></ul>
  46. 47. PT Intervention <ul><li>Postural/ergonomic education </li></ul><ul><li>Repeated movements in direction of preference </li></ul><ul><li>Manual physical therapy </li></ul><ul><li>Spine stabilization </li></ul><ul><li>Muscle balance </li></ul><ul><li>Traction </li></ul><ul><li>Physical agents </li></ul>
  47. 48. References Evidence based practice