University of Delaware Cervical-Throacic Evaluation and Treatment Development of a Clinical...

University of Delaware

Cervical-Throacic Evaluation and Cervical-Throacic Evaluation and TreatmentTreatment

Development of a Clinical Prediction Development of a Clinical Prediction RuleRule

Tara Jo Manal PT, DPT, OCS, SCSTara Jo Manal PT, DPT, OCS, SCS

Greg Hicks PT, PhDGreg Hicks PT, PhD


Special TestsSpecial Tests

Debate in the meaningfulness and Debate in the meaningfulness and usefulness of Vertebral Artery Testingusefulness of Vertebral Artery Testing

? Interpretation of a negative test? Interpretation of a negative test

If positive, further evaluation is indicatedIf positive, further evaluation is indicated


Vertebral Artery TestVertebral Artery Test Combined Movements Combined Movements

to stress test the to stress test the cervical spinecervical spine

Symptoms: Symptoms: – Dizziness -TinnitusDizziness -Tinnitus

– LightheadednessLightheadedness

– Nystagmus -ParathesiaNystagmus -Parathesia

– Dysarthria - DiplopiaDysarthria - Diplopia

– DysphagiaDysphagia


Vertebral Artery Preliminary Vertebral Artery Preliminary TestTest

Patient is sitting. Sustain cervical extension Patient is sitting. Sustain cervical extension for 10 seconds.for 10 seconds.

Sustain Rotation (L and R) 10 secondsSustain Rotation (L and R) 10 seconds IF POSITIVE STOPIF POSITIVE STOP If the testing is negative progress to If the testing is negative progress to

standard position.standard position.


Vertebral Artery Standard TestVertebral Artery Standard Test

Patient is supine. Sustain cervical extension Patient is supine. Sustain cervical extension for 10 seconds. for 10 seconds.

Sustain Rotation (L and R) for 10 secondsSustain Rotation (L and R) for 10 seconds Combine Extension with Rotation (L and R) Combine Extension with Rotation (L and R)

for 10 seconds.for 10 seconds. Test the patient in the Test the patient in the manipulationmanipulation

positionposition IF POSITIVE IF POSITIVE STOPSTOP, do not manipulate, do not manipulate


Cervical DistractionCervical Distraction

Nerve Root Nerve Root CompressionCompression

Radicular pain is Radicular pain is decreased, test is decreased, test is positivepositive


Cervical Compression TestCervical Compression Test

Pressure downward on Pressure downward on headhead

Test is positive if pain Test is positive if pain is evokedis evoked


Spurling ASpurling A

SeatedSeated Neck Side bent to the Neck Side bent to the

ipisilateral sideipisilateral side 7kg of overpressure 7kg of overpressure

appliedapplied

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


Spurling BSpurling B

SeatedSeated ExtensionExtension Sidebending and Sidebending and

Rotation to the Rotation to the ipsilateral sideipsilateral side

7kg of axial pressure 7kg of axial pressure is appliedis applied


Sharp –Purser TestSharp –Purser Test

Neck in semi flexionNeck in semi flexion Palm of one hand on Palm of one hand on

foreheadforehead Index finger on Index finger on

Spinous process C2Spinous process C2 Posterior force Posterior force

through foreheadthrough forehead Posterior slide is + for Posterior slide is + for

AA instabilityAA instability


Shoulder Abduction SignShoulder Abduction Sign

Most common nerve Most common nerve root compression at root compression at C5-6C5-6

Decrease in symptoms Decrease in symptoms is positive responseis positive response


Median Nerve TestingMedian Nerve Testing

Shoulder Retraction Shoulder Retraction and Depressionand Depression

Shoulder ExtensionShoulder Extension External RotationExternal Rotation Elbow ExtensionElbow Extension Forearm SupinationForearm Supination Wrist/Finger Wrist/Finger

ExtensionExtension Cervical SB and Rot Cervical SB and Rot

AwayAway


Upper Limb Tension Testing AUpper Limb Tension Testing A

Scapular DepressionScapular Depression Shoulder AbductionShoulder Abduction Shoulder ERShoulder ER Elbow ExtensionElbow Extension Forearm SupForearm Sup Wrist and Finger Wrist and Finger

ExtensionExtension


Radial Nerve TestingRadial Nerve Testing

Proximal as for Proximal as for MedianMedian

Shoulder Internal RotShoulder Internal Rot Forearm PronationForearm Pronation Wrist FlexionWrist Flexion Ulnar DeviationUlnar Deviation Finger FlexionFinger Flexion


Upper Limb Tension Testing BUpper Limb Tension Testing B

Supine in 30Supine in 30º Abdº Abd Scap DepressionScap Depression Shoulder IRShoulder IR Elbow ExtensionElbow Extension Wrist and Finger Wrist and Finger

FlexionFlexion Opposite Cervical SB Opposite Cervical SB

and Rotand Rot


Ulnar Nerve TestingUlnar Nerve Testing

Shoulder RetractionShoulder Retraction Shld Ext and ERShld Ext and ER Elbow FlexionElbow Flexion Forearm SupinationForearm Supination Wrist Extension and Wrist Extension and

Radial DeviationRadial Deviation Finger ExtensionFinger Extension Cervical SB and Rot Cervical SB and Rot

awayaway


T1 Nerve Root StretchT1 Nerve Root Stretch

Abduct to 90Abduct to 90ºº Flex pronated arms to Flex pronated arms to

9090º º Flex elbows and place Flex elbows and place

behind the neckbehind the neck Pain in scapular area is Pain in scapular area is

T1- Pain in Ulnar T1- Pain in Ulnar distribution is Ulnardistribution is Ulnar


Thoracic OutletThoracic Outlet

Roos TestRoos Test– Standing Abduct arm Standing Abduct arm

to 90to 90°°– ER shoulderER shoulder– Open and Close hand Open and Close hand

for 3 minutesfor 3 minutes Positive if unable to Positive if unable to

maintain position or maintain position or heaviness/tingling in heaviness/tingling in armarm



Adson ManeuverAdson Maneuver SupineSupine Palpate Radial PulsePalpate Radial Pulse Abduct, Extend and Abduct, Extend and

ER armER arm Take deep breath and Take deep breath and

rotate toward armrotate toward arm + Subclavian if change + Subclavian if change

in radial pulsein radial pulse



Halstead ManeuverHalstead Maneuver Palpate radial pulse Palpate radial pulse

and distract UEand distract UE Patient extends and Patient extends and

rotates cervical spine rotates cervical spine to opposite sideto opposite side

Positive for TOS if Positive for TOS if absence of pluseabsence of pluse


Cervical EvaluationCervical Evaluation

Tara Jo Manal PT, DPT, OCS, SCSTara Jo Manal PT, DPT, OCS, SCS

Greg Hicks PT, PhDGreg Hicks PT, PhD


Determining SeverityDetermining Severity

Stage 1Stage 1– Inability to perform basic mechanical functionsInability to perform basic mechanical functions

» Stand for 15 minutesStand for 15 minutes» Sit for 15 minutesSit for 15 minutes» Walk greater than ¼ mileWalk greater than ¼ mile

– Cervical Oswestry (NDI) Cervical Oswestry (NDI) ≥ 30%≥ 30%» Often as high as 50% (less than 2 wks otherwise r/o Often as high as 50% (less than 2 wks otherwise r/o

symptom magnification)symptom magnification)

– Tx- Pain modulation and movementTx- Pain modulation and movement


Stage 1 TreatmentStage 1 Treatment

Joint Manipulation\MobilizationJoint Manipulation\Mobilization TractionTraction Active Spinal MovementActive Spinal Movement Sleeping PosturesSleeping Postures NSAIDSNSAIDS Physical AgentsPhysical Agents Cervical Collar (rest from function only)Cervical Collar (rest from function only)



Stage IIStage II– Unable to carry out ADL’s Unable to carry out ADL’s

» Vacuum, lift, push, pullVacuum, lift, push, pull

– Oswestry (NDI) 20-30%Oswestry (NDI) 20-30% TreatmentTreatment

– WeaknessWeakness– TightnessTightness– PosturePosture– Body MechanicsBody Mechanics– Active ExerciseActive Exercise



Stage IIIStage III– Can perform ADL’s and high demand for brief time Can perform ADL’s and high demand for brief time

periodsperiods– Cannot return fully to high demand activitiesCannot return fully to high demand activities

» Sports, occupational duties, deconditionedSports, occupational duties, deconditioned

– Cervical Oswestry(NDI) Cervical Oswestry(NDI) ≤ 20%≤ 20% Treatment- Return to work/playTreatment- Return to work/play

– Ergonomic Assessment/ModificationsErgonomic Assessment/Modifications– EnduranceEndurance


Assessment of MovementAssessment of Movement

Cyriax Capsular PatternCyriax Capsular Pattern– Full flexion, limited extension and Full flexion, limited extension and

symmetrically limited rotation and sidebendingsymmetrically limited rotation and sidebending– Arthritis, inflammation or DJD of the jointsArthritis, inflammation or DJD of the joints– Flexion is not significantly involved since the Flexion is not significantly involved since the

neck tolerates flexion wellneck tolerates flexion well

– Restricted flexionRestricted flexion» Upper Thoracic and Cervicothoracic junctionUpper Thoracic and Cervicothoracic junction


Range of MotionRange of Motion

FlexionFlexion ExtensionExtension Sidebending Sidebending RotationRotation

– Note quantityNote quantity– Quality (deviations/location)Quality (deviations/location)– Symptom provocationSymptom provocation– Active and Passive overpressureActive and Passive overpressure

Clear the shoulder (pain free ROM)Clear the shoulder (pain free ROM)


Non capsular patternNon capsular pattern

Flexion is limited (non capsular)Flexion is limited (non capsular)– Often cervicothoracic or upper thoracic jxnOften cervicothoracic or upper thoracic jxn

Opening RestrictionsOpening Restrictions Closing RestrictionsClosing Restrictions Combination RestrictionsCombination Restrictions

– Significant dysfunctionSignificant dysfunction– Located 2 or more areasLocated 2 or more areas– CompensationsCompensations


Referred SymptomsReferred Symptoms

Closing RestrictionClosing Restriction– Extension and Sidebending reproduce sx’sExtension and Sidebending reproduce sx’s

Limited Cervical Flexion and symptomsLimited Cervical Flexion and symptoms– Not typical decreased cervical flexion with Not typical decreased cervical flexion with

symptoms in upper backsymptoms in upper back Sidebending to opposite side produces Sidebending to opposite side produces

distal symptoms distal symptoms


Upper Quarter ScreenUpper Quarter Screen

Spurling’sSpurling’s Hoffman’s Reflex (Babinski of UE)Hoffman’s Reflex (Babinski of UE) L’hermittesL’hermittes ReflexesReflexes MMTMMT Sensory TestingSensory Testing


Consider Disc Consider Disc

True limitation in cervical flexionTrue limitation in cervical flexion Radiculopathy recreated with motionRadiculopathy recreated with motion Neurological findingsNeurological findings

– Refer for MRIRefer for MRI


Cervical EvaluationCervical Evaluation

Passive Range of Motion with endfeelPassive Range of Motion with endfeel Joint PlayJoint Play

– Central PA glidesCentral PA glides– Prone unilateral PA’s (facet glides)Prone unilateral PA’s (facet glides)– Supine downglidesSupine downglides– Can perform in Neutral, Flexion and ExtensionCan perform in Neutral, Flexion and Extension


Response to Range of MotionResponse to Range of Motion

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

•Stage I Mobs, Traction, Modalities, NSAIDS, Sleeping Stage I Mobs, Traction, Modalities, NSAIDS, Sleeping PosturesPostures

•Stage II Active Exercise, Postural Correction, Daily Stage II Active Exercise, Postural Correction, Daily ActivitiesActivities

•Stage III Ergonomic Assessment and ModificationsStage III Ergonomic Assessment and Modifications

YesYes

Determine Stage and TreatDetermine Stage and Treat


Response to ROMResponse to ROMNo Capsular PatternNo Capsular Pattern

Is Flexion Limited?Is Flexion Limited?

YesYes NoNo

Assess and Tx Assess and Tx

C-T and T jxnC-T and T jxn

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

YesYes

Joint Mobs for openingJoint Mobs for opening

NoNo

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

YesYes

Joint Mobs for closingJoint Mobs for closing

NoNo

Likely a combined lesionLikely a combined lesion


Limited Forward FlexionLimited Forward Flexion

Traction Manip to C-T Junction and ThoracicTraction Manip to C-T Junction and Thoracic

Full Passive Flexion Full Passive Flexion

(see next)(see next)

Forward Flexion Still LimitedForward Flexion Still Limited

Try Cervical TractionTry Cervical Traction

No Change: No Change:

MRI for mechanical blockMRI for mechanical block

Improve:Improve:

ContinueContinue


Full FlexionFull Flexion

Opening RestrictionOpening Restriction

No Radicular SXs during movementNo Radicular SXs during movement

Opening Opening ManipulationManipulation

Radicular SXs during movementRadicular SXs during movement

+TOS signs+TOS signs

Joint Mobs for openingJoint Mobs for opening

-TOS signs-TOS signs

Traction ManipulationTraction Manipulation

+Radicular SXs on Opening+Radicular SXs on Opening

ICTICT

-Radicular SXs on Opening-Radicular SXs on Opening

Opening ManipulationOpening Manipulation


Upper Thoracic ManipulationUpper Thoracic Manipulation

CT junctionCT junction Patient sits far back on Patient sits far back on

tabletable Stabilize shoulders Stabilize shoulders Use their hands as Use their hands as

fulcrumfulcrum Distract upwardsDistract upwards

– Drop downDrop down



Clavicle, 1Clavicle, 1stst Rib and Rib and Costoclavicular lig, Costoclavicular lig, subclavius and ant subclavius and ant scalenescalene

Compression of Compression of subclavian or axiallary subclavian or axiallary artery, vein, or artery, vein, or brachial plexius (C8 brachial plexius (C8 and T1)and T1)

Costoclavicular Costoclavicular syndromesyndrome– Loss space between Loss space between

clavicle and 1clavicle and 1stst rib rib

Cervical Rib (Cervical Rib (<1%) <1%) syndromesyndrome– Cervical rib from C7 or Cervical rib from C7 or

band of fibrous tissue band of fibrous tissue in areain area



Anterior Scalene Anterior Scalene SyndromeSyndrome– Compression of Compression of

neurovascular bundle neurovascular bundle between anterior and between anterior and middle scalesmiddle scales

– Tingling 4Tingling 4thth and 5 and 5thth digitdigit

– Ulnar and Median Ulnar and Median weaknessweakness

– If vascular hand edemaIf vascular hand edema

Testing should Testing should recreate symptomsrecreate symptoms

Vascular change alone Vascular change alone is not predictiveis not predictive

Exacerbated by Exacerbated by shoulder shoulder hypermobilityhypermobility– Dead armDead arm


Full Flexion and Closing RestrictionFull Flexion and Closing Restriction

No Radicular Symptoms on closingNo Radicular Symptoms on closing

Closing ManipulationClosing Manipulation


Full Flexion and Closing RestrictionFull Flexion and Closing Restriction

Traction Manip

Radicular symptoms on closingRadicular symptoms on closing

+ Neuro Signs

+ Radicular

with Closing

-Radicular

with Closing

ICT Closing Manip

- Neuro Signs

Opening Manip

+ Radicular

with Closing

- Radicular

with Closing

Traction Manip Closing Manip


Early Treatment for PainEarly Treatment for Pain 3 Finger Treatments- Painfree ROM3 Finger Treatments- Painfree ROM

– Neck RetractionNeck Retraction– Lateral FlexionLateral Flexion– RotationRotation

Decrease flexion (increase fingers) as pain subsidesDecrease flexion (increase fingers) as pain subsides


Early Treatment for PainEarly Treatment for Pain

RestRest– Throughout day, interrupt activityThroughout day, interrupt activity

Supported SleepSupported Sleep– Butterfly pillow (good cervical pillow)Butterfly pillow (good cervical pillow)

Upright PostureUpright Posture– Avoid hanging headAvoid hanging head– Collar As NeededCollar As Needed


Stage II TreatmentStage II Treatment

Improve RangeImprove Range– Joints, muscles, neural tissueJoints, muscles, neural tissue

Improve StabilityImprove Stability– Strengthen weak musclesStrengthen weak muscles– Improved Postural ControlImproved Postural Control

Improve Aerobic CapacityImprove Aerobic Capacity– Activity enduranceActivity endurance


Self Stretching/Joint MobsSelf Stretching/Joint Mobs

Use hands to stabilize cervical spineUse hands to stabilize cervical spine SNAG’s with towelSNAG’s with towel


Indication for Cervical Indication for Cervical ManipulationManipulation

Most successful in presence of a specific Most successful in presence of a specific restriction (primarily mechanical block)restriction (primarily mechanical block)

TT TendernessTenderness A A AsymmetryAsymmetry RR Restriction of Movement Restriction of Movement TT Tension (muscle and soft tissue) Tension (muscle and soft tissue)

Bourdillon 1970Bourdillon 1970


Differential DiagnosisDifferential Diagnosis

HistoryHistory– Fracture or InstabilityFracture or Instability– Index of SuspicionIndex of Suspicion

Intoxication, LOC, High Energy InjuriesIntoxication, LOC, High Energy Injuries– x-rays x-rays

lateral(flex/ext),AP,open lateral(flex/ext),AP,open mouth,obliquesmouth,obliques

– Osteophytic EncroachmentOsteophytic Encroachment– Whiplash(acceleration injury)Whiplash(acceleration injury)


Contraindications to Contraindications to ManipulationManipulation

Paget’s DiseasePaget’s Disease Rheumatoid ArthritisRheumatoid Arthritis OsetomyelitisOsetomyelitis Ankylosing SpondylitisAnkylosing Spondylitis MalignancyMalignancy Cord and Cauda Equina SyndromeCord and Cauda Equina Syndrome Vertebral Artery InvolvementVertebral Artery Involvement


Complications Due to Complications Due to ManipulationManipulation

Neurovascular ComplicationsNeurovascular Complications AuthorAuthor CasesCases

Sherman, Smialek &ZaneSherman, Smialek &Zane 52 52 GrantGrant 58 58 PatijinPatijin 84 84 TerrettTerrett 107 107 Kunnasmaa & ThielKunnasmaa & Thiel 139 139

(Rivett, Milburn 1996)(Rivett, Milburn 1996)


Lee et al. Neurology 1995Lee et al. Neurology 1995

Survey of 177 NeurologistsSurvey of 177 Neurologists Report of neurologic complications Report of neurologic complications

following chiropractic manipulationfollowing chiropractic manipulation 102 Complications102 Complications

56 Strokes56 Strokes13 Myelopathies13 Myelopathies

22 Radiculopathies22 Radiculopathies


Hurtwitz et al. 1996 SpineHurtwitz et al. 1996 Spine Complication RateComplication Rate

– 5-10 in 5 to 10 million5-10 in 5 to 10 million– Less than 120 cases in English Less than 120 cases in English

» Primarily Vertebrobasilar accident (VBA)Primarily Vertebrobasilar accident (VBA) Brain stem or cerebellar infarctBrain stem or cerebellar infarct

» Cord compression, Fracture, Tracheal ruptureCord compression, Fracture, Tracheal rupture» Diaphragm paralysis, carotid hematoma or cardiac Diaphragm paralysis, carotid hematoma or cardiac

arrestarrest


Injury on 118 ComplicationsInjury on 118 Complications

Initial ComplaintsInitial Complaints 37 (31.5%) Neck Pain37 (31.5%) Neck Pain 10 (8.5%) Neck stiffness10 (8.5%) Neck stiffness 17 (14.5%) Head and neck pain or stiffness17 (14.5%) Head and neck pain or stiffness 23 (19.5%) Headaches23 (19.5%) Headaches 31 (26%) Other31 (26%) Other

– Torticollis, back pain, head coldsTorticollis, back pain, head colds


Injury in ManipulationInjury in Manipulation

82% were rotational manipulations82% were rotational manipulations 66% had signs or symptoms of VBA66% had signs or symptoms of VBA

– After first manipulationAfter first manipulation 78% had consequences of VB ischemia78% had consequences of VB ischemia

– 20 died20 died– 42 had residual symptoms42 had residual symptoms

Risk for Mild complication 1 in 40,000Risk for Mild complication 1 in 40,000 Risk for Serious complication 1 in 1 millionRisk for Serious complication 1 in 1 million


Complications Resulting from Complications Resulting from Treatments of the C-spineTreatments of the C-spine

TreatmentTreatment Complication Complication ManipulationManipulation VBA, Major VBA, Major

Complication or DeathComplication or Death– 5-10/10,000,0005-10/10,000,000

Cervical SurgeryCervical Surgery– 15.6/100015.6/1000 Neurological CompromiseNeurological Compromise– 6.9/10006.9/1000 DeathDeath

NSAIDSNSAIDS Serious GI eventSerious GI event 3.2/1000 (age 65+)3.2/1000 (age 65+) Bleeding, perforation, or other Bleeding, perforation, or other .39/1000 .39/1000

(<65) (<65) resulting in hospitalization or deathresulting in hospitalization or death 1/1000 (Ages combined)1/1000 (Ages combined)


ExaminationExamination

Perform an Upper Quarter ScreenPerform an Upper Quarter Screen– Check dermatomesCheck dermatomes– Check myotomesCheck myotomes– Check reflexesCheck reflexes


Range of Motion Range of Motion

Cervical spine facet motionCervical spine facet motion– Flexion causes facet openingFlexion causes facet opening– Extension causes facet closingExtension causes facet closing– Rotation and Lateral Flexion(SB) occur in the Rotation and Lateral Flexion(SB) occur in the

same directionsame direction– Rotation and Lateral Flexion cause facet Rotation and Lateral Flexion cause facet

opening contralerally and closing ipsilaterallyopening contralerally and closing ipsilaterally


Cervical Facet Opening/ClosingCervical Facet Opening/Closing

Maximal Left OpeningMaximal Left Opening– Forward FlexionForward Flexion

– Right RotationRight Rotation

– Right SidebendingRight Sidebending

Maximal Left ClosingMaximal Left Closing– ExtensionExtension

– Left RotationLeft Rotation

– Left SidebendingLeft Sidebending


Treatment/ManipulationTreatment/Manipulation

To Open or Close?To Open or Close?– Force a stuck drawer closeForce a stuck drawer close– Open the drawer fully and then attempt to close Open the drawer fully and then attempt to close

itit


Cervical Manipulation ProcedureCervical Manipulation Procedure Position patient comfortablyPosition patient comfortably Palpate the cervical treatment levelPalpate the cervical treatment level Flex or Extend the neck until Flex or Extend the neck until

tension/approximation is noted at the spinal tension/approximation is noted at the spinal interspace above the desired levelinterspace above the desired level

Rotate the head to end rangeRotate the head to end range During patient exhalation - stress end rangeDuring patient exhalation - stress end range Quickly overpress when the patient relaxesQuickly overpress when the patient relaxes Reassess the patient’s movement and recordReassess the patient’s movement and record


Manipulation Position for Right Manipulation Position for Right Cervical ClosingCervical Closing


Alternative to ManipulationAlternative to Manipulation

Follow the outlined treatment(no overpress)Follow the outlined treatment(no overpress)– Oscillate the head at end rangeOscillate the head at end range

Traction (manual or mechanical)Traction (manual or mechanical) Soft tissue TreatmentSoft tissue Treatment

– ModalitiesModalities– MassageMassage

Seek training with skilled manipulatorSeek training with skilled manipulator Refer patient to skilled manipulatorRefer patient to skilled manipulator


Myth of ManipulationMyth of Manipulation

Manipulation is notManipulation is not– Dealing with dislocation/subluxationDealing with dislocation/subluxation– Correcting a “little bone out of place”Correcting a “little bone out of place”– Restoring a “slipped disc”Restoring a “slipped disc”

Manipulation isManipulation is– Designed to overcome a motion restrictionDesigned to overcome a motion restriction


Cervical RadiculopathyCervical Radiculopathy


Cervical CaseCervical Case


Reliability and Accuracy of Reliability and Accuracy of Clinical Exam for Cervical Clinical Exam for Cervical

RadiculopathyRadiculopathy Wainner Spine 2003Wainner Spine 2003 82 Patients with suspected Cervical 82 Patients with suspected Cervical

radiculopathy or carpel tunnel radiculopathy or carpel tunnel Electrophysiological Testing Electrophysiological Testing

– Nerve Conduction Study Nerve Conduction Study – Needle ElectromyographyNeedle Electromyography

Clinical ExamClinical Exam– 34 items and 2 raters34 items and 2 raters


Wainner Spine 2003Wainner Spine 2003

Data CollectedData Collected– Visual Analog ScaleVisual Analog Scale

– NDINDI

– History QuestionsHistory Questions

– MMT of Upper QuarterMMT of Upper Quarter

– ReflexesReflexes

– Pin prick sensationPin prick sensation

– Cervical ROMCervical ROM» 2 warm up- 1 trial with inclinometer2 warm up- 1 trial with inclinometer


Provocative TestsProvocative Tests

Induce or alleviate mechanical pressureInduce or alleviate mechanical pressure

Enlarge neural foramenEnlarge neural foramen Stretch or slacken neural elementsStretch or slacken neural elements Increase intrathecal pressureIncrease intrathecal pressure


Wainner Spine 2003Wainner Spine 2003

Provocative TestingProvocative Testing– Spurling ASpurling A– Spurling BSpurling B– Shoulder Abduction TestShoulder Abduction Test– Valsalva ManeuverValsalva Maneuver– Neck DistractionNeck Distraction– Upper Limb Tension A and BUpper Limb Tension A and B



Upper Limb Tension Test A (symptoms Upper Limb Tension Test A (symptoms recreated, recreated, ≥10° elbow ext. difference or ≥10° elbow ext. difference or wrist flexion, cervical SB’ing increases sx.wrist flexion, cervical SB’ing increases sx.))

Involved Cervical Rotation less than 60 Involved Cervical Rotation less than 60 degreesdegrees

Distraction Test (Supine examiner distracts- Distraction Test (Supine examiner distracts- symptoms reduced)symptoms reduced)

Spurling A (Sidebend with compression)Spurling A (Sidebend with compression)



Upper Limb Tension Test AUpper Limb Tension Test A Involved Cervical Rotation of less than 60Involved Cervical Rotation of less than 60°° Distraction Test (Reduces symptoms)Distraction Test (Reduces symptoms) Spurling A Spurling A

– ( if negative best to rule out)( if negative best to rule out)

2 Tests = 21%2 Tests = 21% 3 tests= 65%3 tests= 65% 4 Tests= 90% 4 Tests= 90%

Reference Criterion- Electrophysiological TestingReference Criterion- Electrophysiological Testing


Radiculopathy TreatmentRadiculopathy Treatment

Cleland JOSPT 2005Cleland JOSPT 2005 Diagnosis based on Wainner et al.Diagnosis based on Wainner et al.

Case Series of 10 patientsCase Series of 10 patients 6 month Follow up6 month Follow up


SubjectsSubjects

11 of 28 satisfied criteria11 of 28 satisfied criteria Age = Age = 51.7 (S.D. 8.2) 51.7 (S.D. 8.2) Symptom Duration= Symptom Duration= 18 weeks (8-52) 18 weeks (8-52) Treatments = Treatments = 7.1 (6-10) 7.1 (6-10) 9 of 11 had neck & upper extremity 9 of 11 had neck & upper extremity

painpain(82%)(82%)


TreatmentTreatment

Cervical and Thoracic MobilizationsCervical and Thoracic Mobilizations Deep neck flexor Deep neck flexor

– Supine flattening cervical lordosis with nodSupine flattening cervical lordosis with nod– 10 second hold/ 10 reps10 second hold/ 10 reps

Scapular exercisesScapular exercises– Middle and Lower trap (prone on plinth)Middle and Lower trap (prone on plinth)– Serratus Wall push upsSerratus Wall push ups

Mechanical traction to centralize or reduce sx’sMechanical traction to centralize or reduce sx’s– Intermittent 30:10 for 15 minutesIntermittent 30:10 for 15 minutes– 8.2 kg (18lbs) increased .5-1kg/visit8.2 kg (18lbs) increased .5-1kg/visit


Cervical Lateral GlidesCervical Lateral Glides


Thoracic ManipulationsThoracic Manipulations


OutcomesOutcomes

Discharge: 8 of 11 (73%) were negative on cluster Discharge: 8 of 11 (73%) were negative on cluster of testsof tests– 2 had positive Spurling’s but improved function2 had positive Spurling’s but improved function– 1 had ULTT and Suprling’s1 had ULTT and Suprling’s

10 Patients (91%) had clinically meaningful 10 Patients (91%) had clinically meaningful reductions in pain and disability reductions in pain and disability – ((> 2-7pt change)> 2-7pt change)– Lasted for 6 months- Lasted for 6 months-

» 45 % had 10/1045 % had 10/10» 50% had mild limitations50% had mild limitations


Expand CriteriaExpand Criteria

If treatment aimed at thoracic helps with If treatment aimed at thoracic helps with radiculopathy- how about neck pain?radiculopathy- how about neck pain?


SubjectsSubjects

Primary Complaint of Mechanical Neck Primary Complaint of Mechanical Neck PainPain– Nonspecific pain in cervicothoracic jxn Nonspecific pain in cervicothoracic jxn

worsened with neck movementsworsened with neck movements NDINDI VAS (0-100)VAS (0-100) 36 subjects36 subjects


Randomized TreatmentRandomized Treatment

Thoracic manipulationThoracic manipulation

Sham ManipulationSham Manipulation


Immediate Response to Immediate Response to ManipulationManipulation


Clinical Prediction RuleClinical Prediction Rule

Which patients with neck pain can benefit Which patients with neck pain can benefit from thoracic manipulation, exercise, and from thoracic manipulation, exercise, and patient education?patient education?

Cleland et al. Physical Therapy 2007Cleland et al. Physical Therapy 2007


Clinical Prediction Rule for Neck Clinical Prediction Rule for Neck PainPain

Age- 18-60 Neck pain with and

without unilateral arm symptoms

NDI > 10% 10% Exclusions: Red flags, Exclusions: Red flags,

whiplash < 6 weeks, whiplash < 6 weeks, cervical spinal stenosis, cervical spinal stenosis, CNS problemCNS problem– 2 signs of nerve root 2 signs of nerve root

myotomes, sensation, myotomes, sensation, reflexesreflexes

Numeric Pain RatingNumeric Pain Rating NDI and FABQNDI and FABQ Distal symptom localDistal symptom local Various measurementsVarious measurements

– Neurological ScreenNeurological Screen– Postural assessmentPostural assessment– Cervical ROMCervical ROM– Joint MobilityJoint Mobility– Strength/endurance of Strength/endurance of

musclesmuscles– Spurlings, Roos, Spurlings, Roos,

Distraction, ULTTDistraction, ULTT


InterventionIntervention

3 Thrust 3 Thrust ManipulationsManipulations– 2 reps of each2 reps of each

Seated DistractionSeated Distraction



Supine Upper Supine Upper Thoracic ManipThoracic Manip



Supine Middle Supine Middle Thoracic ManipulationThoracic Manipulation


Other InterventionOther Intervention

Cervical ROMCervical ROM


OutcomesOutcomes Greater than +5 point Greater than +5 point

change on global rating of change on global rating of changechange

If not achieved after If not achieved after treatment 1, repeated on treatment 1, repeated on next treatmentnext treatment

No +5 after 2 treatments= No +5 after 2 treatments= Non ResponderNon Responder

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