CervicothoracicSpine Assessment Ppt
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Transcript of CervicothoracicSpine Assessment Ppt
Overview of Manual Therapy Assessment and Treatment of
the Cervicothoracic Spine
Megan Casey Douglas, PT, DPT, MTC, OCS
Megan Casey Douglas, PT, DPT, MTC, OCS
Bellingham, WA Director of Physical
Therapy at Northwest Physical Therapy- Skagit Valley, Private Practice
Recently moved from Cincinnati, OH
DPT, MTC thru University of St. Augustine
OCS thru APTA MPT – Andrews University
BS- Miami University Teaching Experience
Adjunct University of Dayton College of Mt. St. Joseph Continuing Education
WHAT IS MANUAL THERAPY?
A clinical approach utilizing skilled, specific hands-on techniques, including but not limited to manipulation/mobilization, used by the physical therapist to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion (ROM); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and non-contractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function.1,2
(Definition from American Academy of Orthopedic Manual Physical Therapy (AAOMPT) and American Physical Therapy Association (APTA).
Anatomy of the Cervical Spine
Anatomy of the Cervical Spine
Spinous ProcessArticular pillar
formed by articular process and interarticularpartsZygapophyseal
joints- 45⁰At T1 – 1st costal
facet for 1st rib
Mid-Cervical Vertebra
BodyTransverse ProcessAnterior tuberclePosterior tubercleGroove for spinal N.Transverse foramenPedicleSuperior articular
facet Inferior articular
processVertebral foramenSpino s process
C4 Vertebra – vs – C7
Anatomy of C1 and C2
Atlas (c1) Anatomy Axis (C2) Anatomy
Ligaments of the Cervical Spine
Tectorial membrane
becomes PLL
Capsule of OA joint
Capsule of AA joint
Capsule of zygapophyseal joint
Posterior view (s.p. removed)
Ligaments of the Cervical Spine
Anterior Longitudinal Ligament
Anterior view
Ligaments of the OA joint
Alar ligaments
Cruciate ligament
Apical ligament of dens
Posterior view
Cervical Spine Ligaments
Ligamentumnuchae
Ligamenta flava
Spinous process of C7 vertebra
Vertebral a.
Right Lateral View
Cervical Spine Musculature
Cervical Spine Musculature
Cervical Spine Musculature
Biomechanics of the Cervical Spine
Biomechanics of the Cervical Spine
Biomechanics of Cervical Spine
Mid cervical forward bending Facets slide up,
approx. 40% displacement
Lateral interbodyjoints slide forward
Vertebrae step minimally
Spinal canal narrows but lengthens, volume remains the same.
Biomechanics of Cervical Spine
Mid Cervical Backward BendingFacets slide down, then fulcrum on pedicle.
Lateral interbodies slide backVertebrae step considerably!!
Ligamentum flavum bulges inward
Spinal canal shortens and narrows significantly
Cord may be compressed in the presence of degenerative changes
Biomechanics of Cervical Spine
Mid Cervical Sidebending /Rotation RightFacets slide down and back on the right
Facets slide up and forward on the left, causing right rotation
Biomechanics of Cervical Spine
If patient is instructed to face forward with sidebending Right, AA Rotation Left has occurred.
If patient is instructed to rotate right, keeping eyes level with the horizon, SB Left occurs subcranially (OA, AA).
Approx. half of cervical rotation originates from the AA joint (C1/C2).
Anatomy/Biomechanics of the upper thoracic spine
T1 has a unifacetfor articulation of the first rib
T1 through T3 generally follow lower cervical biomechanics
Lower thoracic segments similar to lumbar spine
Cervical Evaluation
Cervical Evaluation
Observation/ PostureSymmetry, resting position of head on neckForward Head Posture (FHP)Increase/Decrease in thoracic kyphosis
AROM testingFlexion, Extension, SB R/L, ROT R/LVeers R/L with flexion/extensionSB R/L, seated, arms supported/ unsupported
Rotation- should recruit down to approx. T3OA nodding/SB, AA rotation
Cervical Evaluation
Neurovascular assessmentSpecial TestsAlar Odontoid IntegrityTransverse LigamentVertebral A.??
Precautions, trauma, diagnostic tests
Cervical Evaluation
PROM/joint mobility testingSupine, neutral to slight flexionOA/ AA mobilityCheck SB R/L, Rot R/LCervical upglidesCervical downglidesUpper thoracic joint mobility (from supine, PA)1st rib mobility
Muscle length, Soft tissue restrictionsPalpation
Cervical Evaluation
Video Demonstration Cervical upglides
Cervical downglides
Upper thoracic PA mobility
1st rib mobility- depression
Cervical and Upper Thoracic Manipulation
Indications for Manipulation
Restricted accessory joint motion
Neurophysiological benefit and pain control.
Contraindications/Precautions for Manipulation
Disease statesHemarthrosisHypermobilityMuscle holdingFractureAcute inflammationFusion/Joint replacementAnticoagulant therapyOsteoporosis
Grades of Manipulation
Grades of Manipulation
Non-ThrustMaitland- Grade I
Grade IIGrade IIIGrade IV
Traditional- stretchParis- progressive
oscillationMulligan- mobilizes with active
movement
ThrustTraditional- High Velocity Low Amplitude (HVLAT)
DistractionTraditional- Manual
MechanicalParis- Positional
Cervical Manipulation Techniques-Video Demonstration
Cervical upglides
Cervical downglides
Upper thoracic PA mobility
1st rib mobility- depression
Cervical Traction
Suboccipital Release/Inhibitive Distraction
Common Diagnoses that may benefit from Manual Therapy
Cervical DDD
Cervical OA, facet arthropathy
Cervical RadiculopathyDisc protrustion/herniation
Foramenal stenosis due to OA
Cervical Sprain/Strain
Cervicogenic Headache
Forward Head Posture can contribute to...
Muscle Imbalance/ Adaptive shorteningJoint restrictionsAreas of relative hypo/hypermobilityFacet arthropathyDDD Compromise of neural foramen
Cervicogenic HeadachesThoracic Outlet SyndromeTMJ disorders
Key Tips to Remember
Treatment to improve posture/ reduce FHP and optimize intended cervical spine biomechanics
Treat joint restrictions with manipulation
Stabilize areas of hypermobility
Avoid manipulative forces thru hypermobilesegments
Key Tips to Remember
Joint restrictions may not be where the patient complains of pain/tenderness
Pain is deceiving/ referral patterns
Key Tips to Remember
After acute phase/palliative treatments, go to the source of the problemDisc protrusion- symptom
Muscle “sprain/strain” may be guarding due to underlying problem
Cervicogenic HeadacheFHP?
Joint restriction of OA, AA
Case Study 1
Cervical RadiculopathyManual Therapy Treatment
Patient is a 39 y/o CPA (in April!) and has a pronounced FHP
Pain increases Rotation R, SB R, and Ext.
Intermittent R UE burning down to elbow, n/t in R hand
Weakness in C6 myotome
Tenderness over R
Acute phase Manual traction
straight pulladd slight SB L/ Rot L, flex
Suboccipital release
Subacute Cervical upglides on R? Upper thoracic manipulation 1st rib depression
Chronic Address other joint
restrictions, soft tissue restrictions
Case Study 2
Left Upper TrapeziusStrain
Manual Therapy Treatment
Patient is a 24 y/ostudent, woke with pain on L side of neck
Pain and decreased L SB and L Rotation and Ext. ROM
Pain and decreased downglide C3/C4 facet
Trigger point in L UT and pain with L UT
Cervical downglideson Left side
If c/o pain with downglide, try cervical upglides on Right side.
Recheck joint mobility
Reassess L UT, may try massage/stretching if
Case Study 3
Cervical DDD, HAsManual Therapy Treatment
Patient is a 58 y/ofemale, complaining of bilateral neck pain and headaches
X-rays show DDD at C5/C6 and C6/C7
Patient has sedentary desk job and a significant FHP/increased thoracic kyphosis
Denies radicular Sx Complains of increasing
HAs as work day
Posture! Education/Ergonomics
Manipulate joint restrictions- upper/mid thoracic, upper/mid cervical?
Caution: hypermobility at C5/6, C6/7??
Suboccipital Release/ Inhibitive distraction
OA, AA manipulations if restrictions present- also may decrease Has
Address soft tissue t i ti l
Evidence Supporting Manual Therapy of the Cervical Spine
Bronfort G, Haas M, Evans R, Bouter L. 2004 Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain: a Systematic Review and Best Evidence Synthesis. The Spine Journal, 4(3):335-56.
Eldridge L, Russell J. 2005. Effectiveness of Cervical Spine manipulation and Prescribed Exercise in Reduction of Cervicogenic Headache Pain and Frequency. International J of Osteopathic Med. 8:106-113.
Fernandez-de-las-Penas C, Alsonso-Blanco C, San-Roman J, Miangolarra-Page JC. Methodological Quality of Randomized Controlled Trials of Spinal Manipulaiton and Mobilzation in Tension-Type Headache, Migraine, and Cervicogenic Headache. JOSPT 2006 Mar;36(3):160-9.
Gross A, Hoving J, Haines T, et.al. 2004 A Cochrane Review of Manpulation and Mobilization for Mechanical Neck Disorders. Spine29(14):1541-1548.
Evidence Supporting Manual Therapy of the Cervical Spine
Jull G, Trott P, Potter H. et. al. 2002. A Randomized Controlled Trial of Exercise and Manipulative Therapy for CervicogenicHeadache. Spine 27(17)1835-1843.
Lessinck M, Damen L, Verhagen A. et. al. 2004 The Effectiveness of Physiotherapy and Manipulation in Patinets with Tension-Type Headache: A Systematic Review. Pain 112:381-388.
McNair PJ, Portero P, Chiquet C, Mawston G, Lavaste F. Acute Neck Pain: Cervical Spine Range of Motion and Position Sense prior to and after Joint Mobilization. Man. Ther. 2007 Nov;12(4)390-4.
Zito G, Jull G, Story I. 2006. Clinical Tests of Musculoskeletal Dysfunction in the Diagnosis of Cervicogenic Headache. Man. Ther. 11(2):118-129.
References
• Anatomy pictures – Netter, F.H. Atlas of Human Anatomy. 2nd
ed. 1997
• Paris SV. Manipulation and Management of the Spine. S1 thru S4. University of St. Augustine, St. Augsutine, FL 32086
• Greenman PE. Principles of Manual Medicine. Lippincott, Williams, & Wilkins. Philadelphia, PA. 2003
Overview of Manual Therapy Assessment and Treatment of the Cervicothoracic Spine
Megan Douglas, PT, DPT, MTC, OCS
Cross Country EducationLeading the Way in Professional Development.
www.CrossCountryEducation.com
To comply with professional boards/associations standards:• I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally all Planner’s involved do not have any financial relationship.•Requirements for successful completion is attendance for the full session along with a completed session evaluation form.•Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.
Thank You!