Haifa Day 1 Cer Vico Thoracic

8/9/2019 Haifa Day 1 Cer Vico Thoracic

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University of Delaware

Cervical-Throacic Evaluation andCervical-Throacic Evaluation andTreatmentTreatment

Development of a Clinical PredictionDevelopment of a Clinical Prediction

RuleRule

Tara Jo Manal PT, DPT, C!, !C!Tara Jo Manal PT, DPT, C!, !C!

"re# $ic%s PT, PhD"re# $ic%s PT, PhD


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!pecial Tests!pecial Tests

De&ate in the meanin#fulness andDe&ate in the meanin#fulness and

usefulness of 'erte&ral (rtery Testin#usefulness of 'erte&ral (rtery Testin#

) *nterpretation of a ne#ative test) *nterpretation of a ne#ative test

*f positive, further evaluation is indicated*f positive, further evaluation is indicated


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'erte&ral (rtery Test'erte&ral (rtery Test

Com&ined MovementsCom&ined Movementsto stress test theto stress test the

cervical spinecervical spine

!ymptoms+!ymptoms+

Diiness -TinnitusDiiness -Tinnitus .i#htheadedness.i#htheadedness

/ysta#mus -Parathesia /ysta#mus -Parathesia

Dysarthria - DiplopiaDysarthria - Diplopia

Dyspha#iaDyspha#ia


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'erte&ral (rtery Preliminary Test'erte&ral (rtery Preliminary Test

Patient is sittin#0 !ustain cervical e1tensionPatient is sittin#0 !ustain cervical e1tension

for 23 seconds0for 23 seconds0

!ustain Rotation 4. and R5 23 seconds!ustain Rotation 4. and R5 23 seconds

*6 P!*T*'E !TP*6 P!*T*'E !TP

*f the testin# is ne#ative pro#ress to*f the testin# is ne#ative pro#ress to

standard position0standard position0


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'erte&ral (rtery !tandard Test'erte&ral (rtery !tandard Test

Patient is supine0 !ustain cervical e1tensionPatient is supine0 !ustain cervical e1tensionfor 23 seconds0for 23 seconds0

!ustain Rotation 4. and R5 for 23 seconds!ustain Rotation 4. and R5 for 23 seconds

Com&ine E1tension with Rotation 4. and R5Com&ine E1tension with Rotation 4. and R5for 23 seconds0for 23 seconds0

Test the patient in theTest the patient in the manipulationmanipulation position position

*6 P!*T*'E*6 P!*T*'E STOPSTOP, do not manipulate, do not manipulate


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Cervical DistractionCervical Distraction

/erve Root /erve Root

CompressionCompression

Radicular pain isRadicular pain isdecreased, test isdecreased, test is

positive positive


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Cervical Compression TestCervical Compression Test

Pressure downward onPressure downward on

headhead

Test is positive if painTest is positive if painis evo%edis evo%ed


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!purlin# (!purlin# (

!eated!eated

/ec% !ide &ent to the /ec% !ide &ent to theipisilateral sideipisilateral side

7%# of overpressure7%# of overpressureappliedapplied

Presence of pain,Presence of pain, parasthesial or parasthesial or

num&nessnum&ness


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!purlin# 8!purlin# 8

!eated!eated

E1tensionE1tension

!ide&endin# and!ide&endin# and

Rotation to theRotation to theipsilateral sideipsilateral side

7%# of a1ial pressure7%# of a1ial pressure

is appliedis applied


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!harp Purser Test!harp Purser Test

/ec% in semi fle1ion /ec% in semi fle1ion

Palm of one hand onPalm of one hand onforeheadforehead

*nde1 fin#er on*nde1 fin#er on!pinous process C9!pinous process C9

Posterior forcePosterior forcethrou#h foreheadthrou#h forehead

Posterior slide is : forPosterior slide is : for

(( insta&ility(( insta&ility


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!houlder (&duction !i#n!houlder (&duction !i#n

Most common nerveMost common nerve

root compression atroot compression at

C;-


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Median /erve Testin#Median /erve Testin#

!houlder Retraction!houlder Retractionand Depressionand Depression

!houlder E1tension!houlder E1tension

E1ternal RotationE1ternal Rotation

El&ow E1tensionEl&ow E1tension

6orearm !upination6orearm !upination

=rist>6in#er=rist>6in#erE1tensionE1tension

Cervical !8 and RotCervical !8 and Rot(way(way


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Upper .im& Tension Testin# (Upper .im& Tension Testin# (

!capular Depression!capular Depression

!houlder (&duction!houlder (&duction

!houlder ER !houlder ER

El&ow E1tensionEl&ow E1tension 6orearm !up6orearm !up

=rist and 6in#er=rist and 6in#er

E1tensionE1tension


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Radial /erve Testin#Radial /erve Testin#

Pro1imal as forPro1imal as for

MedianMedian

!houlder *nternal Rot!houlder *nternal Rot

6orearm Pronation6orearm Pronation =rist 6le1ion=rist 6le1ion

Ulnar DeviationUlnar Deviation

6in#er 6le1ion6in#er 6le1ion


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Upper .im& Tension Testin# 8Upper .im& Tension Testin# 8

!upine in ?3!upine in ?3@ (&d@ (&d

!cap Depression!cap Depression

!houlder *R !houlder *R

El&ow E1tensionEl&ow E1tension =rist and 6in#er=rist and 6in#er

6le1ion6le1ion

pposite Cervical !8pposite Cervical !8

and Rotand Rot


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Ulnar /erve Testin#Ulnar /erve Testin#

!houlder Retraction!houlder Retraction

!hld E1t and ER !hld E1t and ER

El&ow 6le1ionEl&ow 6le1ion

6orearm !upination6orearm !upination =rist E1tension and=rist E1tension and

Radial DeviationRadial Deviation

6in#er E1tension6in#er E1tension

Cervical !8 and RotCervical !8 and Rotawayaway


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T2 /erve Root !tretchT2 /erve Root !tretch

(&duct to A3(&duct to A3@@

6le1 pronated arms to6le1 pronated arms to

A3A3@@

6le1 el&ows and place6le1 el&ows and place &ehind the nec% &ehind the nec%

Pain in scapular area isPain in scapular area is

T2- Pain in UlnarT2- Pain in Ulnar

distri&ution is Ulnar distri&ution is Ulnar


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Thoracic utletThoracic utlet

Roos TestRoos Test !tandin# (&duct arm!tandin# (&duct arm

to A3to A3BB

ER shoulder ER shoulder

pen and Close handpen and Close handfor ? minutesfor ? minutes

Positive if una&le toPositive if una&le tomaintain position ormaintain position orheaviness>tin#lin# inheaviness>tin#lin# inarmarm


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(dson Maneuver (dson Maneuver

!upine!upine

Palpate Radial PulsePalpate Radial Pulse

(&duct, E1tend and(&duct, E1tend andER armER arm

Ta%e deep &reath andTa%e deep &reath androtate toward armrotate toward arm

: !u&clavian if chan#e: !u&clavian if chan#ein radial pulsein radial pulse


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$alstead Maneuver $alstead Maneuver

Palpate radial pulsePalpate radial pulse

and distract UEand distract UE

Patient e1tends andPatient e1tends androtates cervical spinerotates cervical spine

to opposite sideto opposite side

Positive for T! ifPositive for T! if

a&sence of plusea&sence of pluse


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Cervical EvaluationCervical Evaluation

Tara Jo Manal PT, DPT, C!, !C!Tara Jo Manal PT, DPT, C!, !C!

"re# $ic%s PT, PhD"re# $ic%s PT, PhD


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Determinin# !everityDeterminin# !everity

!ta#e 2!ta#e 2 *na&ility to perform &asic mechanical functions*na&ility to perform &asic mechanical functions

!tand for 2; minutes!tand for 2; minutes

!it for 2; minutes!it for 2; minutes

=al% #reater than mile=al% #reater than mile

Cervical swestry 4/D*5Cervical swestry 4/D*5 ?3F ?3F ften as hi#h as ;3F 4less than 9 w%s otherwise r>often as hi#h as ;3F 4less than 9 w%s otherwise r>o

symptom ma#nification5symptom ma#nification5

T1- Pain modulation and movementT1- Pain modulation and movement


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!ta#e 2 Treatment!ta#e 2 Treatment

Joint ManipulationGMo&iliationJoint ManipulationGMo&iliation

TractionTraction

(ctive !pinal Movement(ctive !pinal Movement

!leepin# Postures!leepin# Postures

/!(*D! /!(*D!

Physical (#entsPhysical (#ents

Cervical Collar 4rest from function only5Cervical Collar 4rest from function only5


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!ta#e **!ta#e ** Una&le to carry out (D.HsUna&le to carry out (D.Hs

'acuum, lift, push, pull'acuum, lift, push, pull

swestry 4/D*5 93-?3Fswestry 4/D*5 93-?3F

TreatmentTreatment =ea%ness=ea%ness

Ti#htnessTi#htness

PosturePosture

8ody Mechanics8ody Mechanics

(ctive E1ercise(ctive E1ercise


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!ta#e ***!ta#e *** Can perform (D.Hs and hi#h demand for &rief timeCan perform (D.Hs and hi#h demand for &rief time

periods periods

Cannot return fully to hi#h demand activitiesCannot return fully to hi#h demand activities

!ports, occupational duties, deconditioned!ports, occupational duties, deconditioned Cervical swestry4/D*5Cervical swestry4/D*5 I 93FI 93F

Treatment- Return to wor%>playTreatment- Return to wor%>play Er#onomic (ssessment>ModificationsEr#onomic (ssessment>Modifications

EnduranceEndurance


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(ssessment of Movement(ssessment of Movement

Cyria1 Capsular PatternCyria1 Capsular Pattern 6ull fle1ion, limited e1tension and6ull fle1ion, limited e1tension and

symmetrically limited rotation and side&endin#symmetrically limited rotation and side&endin#

(rthritis, inflammation or DJD of the oints(rthritis, inflammation or DJD of the oints

6le1ion is not si#nificantly involved since the6le1ion is not si#nificantly involved since thenec% tolerates fle1ion wellnec% tolerates fle1ion well

Restricted fle1ionRestricted fle1ion Upper Thoracic and Cervicothoracic unctionUpper Thoracic and Cervicothoracic unction


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Ran#e of MotionRan#e of Motion

6le1ion6le1ion

E1tensionE1tension

!ide&endin#!ide&endin#

RotationRotation /ote Kuantity /ote Kuantity

Luality 4deviations>location5Luality 4deviations>location5

!ymptom provocation!ymptom provocation

(ctive and Passive overpressure(ctive and Passive overpressure

Clear the shoulder 4pain free RM5Clear the shoulder 4pain free RM5


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/on capsular pattern /on capsular pattern

6le1ion is limited 4non capsular56le1ion is limited 4non capsular5 ften cervicothoracic or upper thoracic 1nften cervicothoracic or upper thoracic 1n

penin# Restrictionspenin# Restrictions

Closin# RestrictionsClosin# Restrictions Com&ination RestrictionsCom&ination Restrictions

!i#nificant dysfunction!i#nificant dysfunction

.ocated 9 or more areas.ocated 9 or more areas

CompensationsCompensations


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Referred !ymptomsReferred !ymptoms

Closin# RestrictionClosin# Restriction

E1tension and !ide&endin# reproduce s1HsE1tension and !ide&endin# reproduce s1Hs

.imited Cervical 6le1ion and symptoms.imited Cervical 6le1ion and symptoms

/ot typical decreased cervical fle1ion with /ot typical decreased cervical fle1ion withsymptoms in upper &ac% symptoms in upper &ac%

!ide&endin# to opposite side produces!ide&endin# to opposite side produces

distal symptomsdistal symptoms


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Upper Luarter !creenUpper Luarter !creen

!purlin#Hs!purlin#Hs

$offmanHs Refle1 48a&ins%i of UE5$offmanHs Refle1 48a&ins%i of UE5

.Hhermittes.Hhermittes

Refle1esRefle1es

MMTMMT

!ensory Testin#!ensory Testin#


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Consider DiscConsider Disc

True limitation in cervical fle1ionTrue limitation in cervical fle1ion

Radiculopathy recreated with motionRadiculopathy recreated with motion

/eurolo#ical findin#s /eurolo#ical findin#s

Refer for MR*Refer for MR*


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Cervical EvaluationCervical Evaluation

Passive Ran#e of Motion with endfeelPassive Ran#e of Motion with endfeel

Joint PlayJoint Play

Central P( #lidesCentral P( #lides

Prone unilateral P(Hs 4facet #lides5Prone unilateral P(Hs 4facet #lides5

!upine down#lides!upine down#lides

Can perform in /eutral, 6le1ion and E1tensionCan perform in /eutral, 6le1ion and E1tension


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Response to Ran#e of MotionResponse to Ran#e of Motion


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Response to Ran#e of MotionResponse to Ran#e of Motion

Capsular Pattern (No Radiculopathy)?Capsular Pattern (No Radiculopathy)?

•Stage I Mobs, Traction, Modalities, NSI!S, SleepingStage I Mobs, Traction, Modalities, NSI!S, Sleeping

PosturesPostures

•Stage II cti"e #$ercise, Postural Correction, !ailyStage II cti"e #$ercise, Postural Correction, !aily

cti"ities cti"ities

•Stage III #rgono%ic ssess%ent and Modi&icationsStage III #rgono%ic ssess%ent and Modi&ications

'es'es

!eter%ine Stage and Treat!eter%ine Stage and Treat

R t RMR t RM


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Response to RMResponse to RMNo Capsular PatternNo Capsular Pattern

Is le$ion i%ited?Is le$ion i%ited?

'es'es NoNo

ssess and T$ ssess and T$

C*T and T +$nC*T and T +$n

Is there an opening Restriction?Is there an opening Restriction?

Yes Yes

Joint Mobs for openingJoint Mobs for opening

NoNo

Is there a Closing Restriction?Is there a Closing Restriction?

Yes Yes

Joint Mobs for closingJoint Mobs for closing

NoNo

Likely a combined lesionLikely a combined lesion

.i it d 6 d 6l i.imited 6orward 6le1ion


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.imited 6orward 6le1ion.imited 6orward 6le1ion

Traction Manip to C*T unction and ThoracicTraction Manip to C*T unction and Thoracic

ull Passi"e le$ionull Passi"e le$ion

(see ne$t)(see ne$t)

or-ard le$ion Still i%itedor-ard le$ion Still i%ited

Try Cer"ical TractionTry Cer"ical Traction

No Change.No Change.

MRI &or %echanical bloc/MRI &or %echanical bloc/

I%pro"e.I%pro"e.

ContinueContinue

6 ll 6le ion6ull 6le1ion


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6ull 6le1ion6ull 6le1ion

0pening Restriction0pening Restriction

No Radicular S1s during %o"e%entNo Radicular S1s during %o"e%ent

0pening0pening

ManipulationManipulation

Radicular S1s during %o"e%entRadicular S1s during %o"e%ent

+T! signs+T! signs

Joint Mobs for openingJoint Mobs for opening

"T! signs"T! signs

Traction Manip#lationTraction Manip#lation

+Radic#lar !$s on pening+Radic#lar !$s on pening

ICTICT

"Radic#lar !$s on pening"Radic#lar !$s on pening

pening Manip#lationpening Manip#lation


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Upper Thoracic ManipulationUpper Thoracic Manipulation

CT unctionCT unction

Patient sits far &ac% onPatient sits far &ac% on

ta&leta&le

!ta&ilie shoulders!ta&ilie shoulders

Use their hands asUse their hands as

fulcrumfulcrum

Distract upwardsDistract upwards

Drop downDrop down


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Clavicle, 2Clavicle, 2stst Ri& andRi& and

Costoclavicular li#,Costoclavicular li#,

su&clavius and antsu&clavius and ant

scalenescalene

Compression ofCompression of

su&clavian or a1iallarysu&clavian or a1iallary

artery, vein, orartery, vein, or

&rachial ple1ius 4C &rachial ple1ius 4C

and T25and T25

CostoclavicularCostoclavicular

syndromesyndrome

.oss space &etween.oss space &etween

clavicle and 2clavicle and 2stst ri&ri&

Cervical Ri& 4Cervical Ri& 4N2F5N2F5syndromesyndrome

Cervical ri& from C7 orCervical ri& from C7 or

&and of fi&rous tissue &and of fi&rous tissue

in areain area


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(nterior !calene(nterior !calene!yndrome!yndrome Compression ofCompression of

neurovascular &undleneurovascular &undle &etween anterior and &etween anterior andmiddle scalesmiddle scales

Tin#lin# OTin#lin# Othth and ;and ;thth di#itdi#it

Ulnar and MedianUlnar and Medianwea%nesswea%ness

*f vascular hand edema*f vascular hand edema

Testin# shouldTestin# should

recreate symptomsrecreate symptoms

'ascular chan#e alone'ascular chan#e alone

is not predictiveis not predictive

E1acer&ated &yE1acer&ated &y

shouldershoulder

hypermo&ilityhypermo&ility

Dead armDead arm


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6ull 6le1ion and Closin# Restriction6ull 6le1ion and Closin# Restriction

No Radicular Sy%pto%s on closingNo Radicular Sy%pto%s on closing

Closing ManipulationClosing Manipulation

ll l i d l i i i


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6ull 6le1ion and Closin# Restriction6ull 6le1ion and Closin# Restriction

Traction Manip

Radicular sy%pto%s on closingRadicular sy%pto%s on closing

2 Neuro Signs

2 Radicular

-ith Closing

*Radicular

-ith Closing

ICT Closing Manip

* Neuro Signs

0pening Manip

2 Radicular

-ith Closing

* Radicular

-ith Closing

Traction Manip Closing Manip

l f iE l T f P i


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Early Treatment for PainEarly Treatment for Pain

? 6in#er Treatments- Painfree RM? 6in#er Treatments- Painfree RM

/ec% Retraction /ec% Retraction .ateral 6le1ion.ateral 6le1ion

RotationRotation

Decrease fle1ion 4increase fin#ers5 as pain su&sidesDecrease fle1ion 4increase fin#ers5 as pain su&sides

E l T f P iE l T f P i


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Early Treatment for PainEarly Treatment for Pain

RestRest

Throu#hout day, interrupt activityThrou#hout day, interrupt activity

!upported !leep!upported !leep

8utterfly pillow 4#ood cervical pillow58utterfly pillow 4#ood cervical pillow5 Upri#ht PostureUpri#ht Posture

(void han#in# head(void han#in# head

Collar (s /eededCollar (s /eeded

! ** T!t ** T t t


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!ta#e ** Treatment!ta#e ** Treatment

*mprove Ran#e*mprove Ran#e

Joints, muscles, neural tissueJoints, muscles, neural tissue

*mprove !ta&ility*mprove !ta&ility

!tren#then wea% muscles!tren#then wea% muscles *mproved Postural Control*mproved Postural Control

*mprove (ero&ic Capacity*mprove (ero&ic Capacity

(ctivity endurance(ctivity endurance

! lf !t t hi >J i t M &! lf !t t hi >J i t M &


46/91


!elf !tretchin#>Joint Mo&s!elf !tretchin#>Joint Mo&s

Use hands to sta&ilie cervical spineUse hands to sta&ilie cervical spine

!/("Hs with towel!/("Hs with towel


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*ndication for Cervical*ndication for Cervical


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Most successful in presence of a specificMost successful in presence of a specific

restriction 4primarily mechanical &loc%5restriction 4primarily mechanical &loc%5

TT TendernessTenderness

AA (symmetry(symmetry R R Restriction of Movement Restriction of Movement

TT Tension 4muscle and soft tissue5 Tension 4muscle and soft tissue5

8ourdillon 2A738ourdillon 2A73

Diff ti l Di iDifferential Dia#nosis


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Differential Dia#nosisDifferential Dia#nosis

$istory$istory

6racture or *nsta&ility6racture or *nsta&ility

*nde1 of !uspicion*nde1 of !uspicion

*nto1ication, .C, $i#h Ener#y *nuries*nto1ication, .C, $i#h Ener#y *nuries

1-rays1-rays

lateral4fle1>e1t5,(P,open mouth,o&liKueslateral4fle1>e1t5,(P,open mouth,o&liKues

steophytic Encroachmentsteophytic Encroachment

=hiplash4acceleration inury5=hiplash4acceleration inury5

Contraindications toContraindications to


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Pa#etHs DiseasePa#etHs Disease

Rheumatoid (rthritisRheumatoid (rthritis

setomyelitissetomyelitis

(n%ylosin# !pondylitis(n%ylosin# !pondylitis Mali#nancyMali#nancy

Cord and Cauda EKuina !yndromeCord and Cauda EKuina !yndrome

'erte&ral (rtery *nvolvement'erte&ral (rtery *nvolvement


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.ee et al /eurolo#y 2AA;.ee et al /eurolo#y 2AA;


52/91


.ee et al0 /eurolo#y 2AA;.ee et al0 /eurolo#y 2AA;

!urvey of 277 /eurolo#ists!urvey of 277 /eurolo#ists

Report of neurolo#ic complicationsReport of neurolo#ic complications

followin# chiropractic manipulationfollowin# chiropractic manipulation

239 Complications239 Complications;< !tro%es;< !tro%es

2? Myelopathies2? Myelopathies

99 Radiculopathies99 Radiculopathies


53/91


$urtwit et al0 2AA< !pine$urtwit et al0 2AA< !pine Complication RateComplication Rate

;-23 in ; to 23 million;-23 in ; to 23 million

.ess than 293 cases in En#lish.ess than 293 cases in En#lish Primarily 'erte&ro&asilar accident 4'8(5Primarily 'erte&ro&asilar accident 4'8(5

8rain stem or cere&ellar infarct8rain stem or cere&ellar infarct

Cord compression, 6racture, Tracheal ruptureCord compression, 6racture, Tracheal rupture

Diaphra#m paralysis, carotid hematoma or cardiacDiaphra#m paralysis, carotid hematoma or cardiac

arrestarrest

*nury on 22 Complications*nury on 22 Complications


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*nury on 22 Complications*nury on 22 Complications

*nitial Complaints*nitial Complaints

?7 4?20;F5 /ec% Pain?7 4?20;F5 /ec% Pain

23 40;F5 /ec% stiffness23 40;F5 /ec% stiffness

27 42O0;F5 $ead and nec% pain or stiffness27 42O0;F5 $ead and nec% pain or stiffness 9? 42A0;F5 $eadaches9? 42A0;F5 $eadaches

?2 49


55/91


*nury in Manipulation*nury in Manipulation

9F were rotational manipulations9F were rotational manipulations


56/91


Treatments of the C-spineTreatments of the C-spineTreatmentTreatment Complication Complication

ManipulationManipulation '8(, Maor'8(, Maor Complication or DeathComplication or Death ;-23>23,333,333;-23>23,333,333

Cervical !ur#eryCervical !ur#ery 2;023332;02333 /eurolo#ical Compromise /eurolo#ical Compromise

23332333 DeathDeath

/!(*D! /!(*D! !erious "* event!erious "* event ?09>2333 4a#e 2333 4a#e 23330?A>2333

4N2333 4(#es com&ined5

E1aminationE1amination


57/91


E1aminationE1amination

Perform an Upper Luarter !creenPerform an Upper Luarter !creen Chec% dermatomesChec% dermatomes

Chec% myotomesChec% myotomes

Chec% refle1esChec% refle1es



58/91



Cervical spine facet motionCervical spine facet motion 6le1ion causes facet openin#6le1ion causes facet openin#

E1tension causes facet closin#E1tension causes facet closin#

Rotation and .ateral 6le1ion4!85 occur in theRotation and .ateral 6le1ion4!85 occur in thesame directionsame direction

Rotation and .ateral 6le1ion cause facetRotation and .ateral 6le1ion cause facet

openin# contralerally and closin# ipsilaterallyopenin# contralerally and closin# ipsilaterally

Cervical 6acet penin#>Closin#Cervical 6acet penin#>Closin#


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Cervical 6acet penin#>Closin#Cervical 6acet penin#>Closin#

Ma1imal .eft penin#Ma1imal .eft penin# 6orward 6le1ion6orward 6le1ion

Ri#ht RotationRi#ht Rotation

Ri#ht !ide&endin#Ri#ht !ide&endin#

Ma1imal .eft Closin#Ma1imal .eft Closin# E1tensionE1tension

.eft Rotation.eft Rotation

.eft !ide&endin#.eft !ide&endin#

Treatment>ManipulationTreatment>Manipulation


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Treatment>ManipulationTreatment>Manipulation

To pen or Close)To pen or Close) 6orce a stuc% drawer close6orce a stuc% drawer close

pen the drawer fully and then attempt to closepen the drawer fully and then attempt to close

itit

Cervical Manipulation ProcedureCervical Manipulation Procedure


61/91


Cervical Manipulation ProcedureCervical Manipulation Procedure Position patient comforta&lyPosition patient comforta&ly

Palpate the cervical treatment levelPalpate the cervical treatment level 6le1 or E1tend the nec% until6le1 or E1tend the nec% until

tension>appro1imation is noted at the spinaltension>appro1imation is noted at the spinalinterspace a&ove the desired levelinterspace a&ove the desired level

Rotate the head to end ran#eRotate the head to end ran#e Durin# patient e1halation - stress end ran#eDurin# patient e1halation - stress end ran#e

Luic%ly overpress when the patient rela1esLuic%ly overpress when the patient rela1es

Reassess the patientHs movement and recordReassess the patientHs movement and record

Manipulation Position for Ri#htManipulation Position for Ri#ht

i l l iC i l Cl i


62/91


Cervical Closin#Cervical Closin#

(lternative to Manipulation(lternative to Manipulation


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(lternative to Manipulation(lternative to Manipulation

6ollow the outlined treatment4no overpress56ollow the outlined treatment4no overpress5 scillate the head at end ran#escillate the head at end ran#e

Traction 4manual or mechanical5Traction 4manual or mechanical5

!oft tissue Treatment!oft tissue Treatment ModalitiesModalities

Massa#eMassa#e

!ee% trainin# with s%illed manipulator !ee% trainin# with s%illed manipulator

Refer patient to s%illed manipulator Refer patient to s%illed manipulator

Myth of ManipulationMyth of Manipulation


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Myth of Manipulationy p

Manipulation is notManipulation is not Dealin# with dislocation>su&lu1ationDealin# with dislocation>su&lu1ation

Correctin# a Slittle &one out of placeCorrectin# a Slittle &one out of place

Restorin# a Sslipped discRestorin# a Sslipped disc

Manipulation isManipulation is

Desi#ned to overcome a motion restrictionDesi#ned to overcome a motion restriction

Cervical RadiculopathyCervical Radiculopathy


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Ce v c d cu op yp y

Cervical CaseCervical Case


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Provocative TestsProvocative Tests


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*nduce or alleviate mechanical pressure*nduce or alleviate mechanical pressure

Enlar#e neural foramenEnlar#e neural foramen

!tretch or slac%en neural elements!tretch or slac%en neural elements *ncrease intrathecal pressure*ncrease intrathecal pressure

=ainner !pine 933?=ainner !pine 933?


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pp

Provocative Testin#Provocative Testin# !purlin# (!purlin# (

!purlin# 8!purlin# 8

!houlder (&duction Test!houlder (&duction Test

'alsalva Maneuver 'alsalva Maneuver

/ec% Distraction /ec% Distraction

Upper .im& Tension ( and 8Upper .im& Tension ( and 8

Cervical RadiculopathyCervical Radiculopathy


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p y

Upper .im& Tension Test ( 4symptomsUpper .im& Tension Test ( 4symptomsrecreated,recreated, 23B el&ow e1t0 difference or23B el&ow e1t0 difference orwrist fle1ion, cervical !8Hin# increases s10wrist fle1ion, cervical !8Hin# increases s1055

*nvolved Cervical Rotation less than


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Upper .im& Tension Test (Upper .im& Tension Test ( *nvolved Cervical Rotation of less than


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Cleland J!PT 933;Cleland J!PT 933; Dia#nosis &ased on =ainner et al0Dia#nosis &ased on =ainner et al0

Case !eries of 23 patientsCase !eries of 23 patients < month 6ollow up< month 6ollow up

!u&ects!u&ects


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22 of 9 satisfied criteria22 of 9 satisfied criteria (#e (#e ;207 4!0D0 095;207 4!0D0 095

!ymptom Duration!ymptom Duration 2 wee%s 4-;952 wee%s 4-;95

Treatments Treatments 702 4


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Cervical and Thoracic Mo&iliationsCervical and Thoracic Mo&iliations Deep nec% fle1orDeep nec% fle1or

!upine flattenin# cervical lordosis with nod!upine flattenin# cervical lordosis with nod

23 second hold> 23 reps23 second hold> 23 reps

!capular e1ercises!capular e1ercises Middle and .ower trap 4prone on plinth5Middle and .ower trap 4prone on plinth5

!erratus =all push ups!erratus =all push ups

Mechanical traction to centralie or reduce s1HsMechanical traction to centralie or reduce s1Hs *ntermittent ?3+23 for 2; minutes*ntermittent ?3+23 for 2; minutes

09 %# 42l&s5 increased 0;-2%#>visit09 %# 42l&s5 increased 0;-2%#>visit

Cervical .ateral "lidesCervical .ateral "lides


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Thoracic ManipulationsThoracic Manipulations


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utcomesutcomes


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Dischar#e+ of 22 47?F5 were ne#ative on clusterDischar#e+ of 22 47?F5 were ne#ative on clusterof testsof tests 9 had positive !purlin#Hs &ut improved function9 had positive !purlin#Hs &ut improved function

2 had U.TT and !uprlin#Hs2 had U.TT and !uprlin#Hs

23 Patients 4A2F5 had clinically meanin#ful23 Patients 4A2F5 had clinically meanin#fulreductions in pain and disa&ilityreductions in pain and disa&ility 44V 9-7pt chan#e5V 9-7pt chan#e5

.asted for < months-.asted for < months- O; F had 23>23O; F had 23>23

;3F had mild limitations;3F had mild limitations

E1pand CriteriaE1pand Criteria


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*f treatment aimed at thoracic helps with*f treatment aimed at thoracic helps withradiculopathy- how a&out nec% pain)radiculopathy- how a&out nec% pain)

!u&ects!u&ects


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Primary Complaint of Mechanical /ec%Primary Complaint of Mechanical /ec%PainPain

/onspecific pain in cervicothoracic 1n /onspecific pain in cervicothoracic 1n

worsened with nec% movementsworsened with nec% movements

/D* /D*

'(! 43-2335'(! 43-2335

?< su&ects?< su&ects

Randomied TreatmentRandomied Treatment


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Thoracic manipulationThoracic manipulation

!ham Manipulation!ham Manipulation

*mmediate Response to*mmediate Response to



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Clinical Prediction RuleClinical Prediction Rule


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=hich patients with nec% pain can &enefit=hich patients with nec% pain can &enefitfrom thoracic manipulation, e1ercise, andfrom thoracic manipulation, e1ercise, and

patient education) patient education)

Cleland et al0 Physical Therapy 9337Cleland et al0 Physical Therapy 9337


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*ntervention*ntervention


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? Thrust? ThrustManipulationsManipulations

9 reps of each9 reps of each

!eated Distraction!eated Distraction


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*ntervention*ntervention


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!upine Middle!upine MiddleThoracic ManipulationThoracic Manipulation

ther *nterventionther *ntervention


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Cervical RMCervical RM

utcomesutcomes


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"reater than :; point"reater than :; point

chan#e on #lo&al ratin# ofchan#e on #lo&al ratin# ofchan#echan#e

*f not achieved after*f not achieved after

treatment 2, repeated ontreatment 2, repeated on

ne1t treatmentne1t treatment

/o :; after 9 treatments /o :; after 9 treatments

/on Responder /on Responder


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Haifa Day 1 Cer Vico Thoracic

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