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
University of Delaware
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
University of Delaware
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
University of Delaware
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.
University of Delaware
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
University of Delaware
Cervical DistractionCervical Distraction
Nerve Root Nerve Root CompressionCompression
Radicular pain is Radicular pain is decreased, test is decreased, test is positivepositive
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
Thoracic OutletThoracic Outlet
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
University of Delaware
Thoracic OutletThoracic Outlet
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
University of Delaware
Cervical EvaluationCervical Evaluation
Tara Jo Manal PT, DPT, OCS, SCSTara Jo Manal PT, DPT, OCS, SCS
Greg Hicks PT, PhDGreg Hicks PT, PhD
University of Delaware
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
University of Delaware
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)
University of Delaware
Determining SeverityDetermining Severity
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
University of Delaware
Determining SeverityDetermining Severity
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
University of Delaware
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
University of Delaware
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)
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
Thoracic OutletThoracic Outlet
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
University of Delaware
Thoracic OutletThoracic Outlet
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
University of Delaware
Full Flexion and Closing RestrictionFull Flexion and Closing Restriction
No Radicular Symptoms on closingNo Radicular Symptoms on closing
Closing ManipulationClosing Manipulation
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
University of Delaware
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
University of Delaware
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)
University of Delaware
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
University of Delaware
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)
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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)
University of Delaware
ExaminationExamination
Perform an Upper Quarter ScreenPerform an Upper Quarter Screen– Check dermatomesCheck dermatomes– Check myotomesCheck myotomes– Check reflexesCheck reflexes
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
Manipulation Position for Right Manipulation Position for Right Cervical ClosingCervical Closing
University of Delaware
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
University of Delaware
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
University of Delaware
Cervical RadiculopathyCervical Radiculopathy
University of Delaware
Cervical CaseCervical Case
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
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
University of Delaware
Cervical RadiculopathyCervical Radiculopathy
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)
University of Delaware
Cervical RadiculopathyCervical Radiculopathy
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
University of Delaware
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
University of Delaware
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%)
University of Delaware
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
University of Delaware
Cervical Lateral GlidesCervical Lateral Glides
University of Delaware
Thoracic ManipulationsThoracic Manipulations
University of Delaware
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
University of Delaware
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?
University of Delaware
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
University of Delaware
Randomized TreatmentRandomized Treatment
Thoracic manipulationThoracic manipulation
Sham ManipulationSham Manipulation
University of Delaware
Immediate Response to Immediate Response to ManipulationManipulation
University of Delaware
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
University of Delaware
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
University of Delaware
University of Delaware
InterventionIntervention
3 Thrust 3 Thrust ManipulationsManipulations– 2 reps of each2 reps of each
Seated DistractionSeated Distraction
University of Delaware
InterventionIntervention
Supine Upper Supine Upper Thoracic ManipThoracic Manip
University of Delaware
InterventionIntervention
Supine Middle Supine Middle Thoracic ManipulationThoracic Manipulation
University of Delaware
Other InterventionOther Intervention
Cervical ROMCervical ROM
University of Delaware
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
University of Delaware
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