Pre-Course Review

Jason Zafereo, PT, OCS, FAAOMPTCli i l O th di R h bilit ti Ed tiClinical Orthopedic Rehabilitation Education

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Objectives

Review key concepts from history-taking, examination, and treatment self-studies

Apply a hypothesis-testing framework to pp y yp gcritically reason through orthopedic patient casesp

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History-taking

Data collection and hypothesis f tiformation

Subjective exam– History of present illness

Onset, Location, Nature, Aggravating/easing, Intensity, Associated symptoms, Timing

– Functional statusMedical History– Medical History Co-morbidities, radiology, prior

treatment, patient goal(s)3

Examination and Treatment

Hypothesis testing during bj ti d t t tobjective exam and treatment

Objective exam– Impairment: ROM, Palpation for

position, Flexibility, MMT– Pathology: ROM Palpation for– Pathology: ROM, Palpation for

condition, Neurological exam, Special testing, Resisted testing

Treatment– Pain, Stiffness, Weakness 4

Critical Reasoning

Hypothesis categories– Pathology

Contractile/non-contractile

Contributing factors– Contributing factors Environmental, Behavioral, Emotional, Physical,

Biomechanical

– Contraindications/precautions– Prognosis

Co-morbidities Flags Healing phase Exam findings Co-morbidities, Flags, Healing phase, Exam findings

– Management Yellow flags, Pain, Stiffness, Weakness, Education5

Case Practice

Read the information immediately under

Narrow your hypothesis list and make a list of the ~3 confirming

SUBJECTIVE for Case 4 List 2-3 pre-history pathology

hypotheses and ~5 subjective

tests you would like to see in your exam for each

Read the exam and attempt to findings you would expect to have for each

Read the history and attempt

“make the features fit” Change hypotheses as needed Finally, list your post-exam

to “make the features fit” your hypotheses

a y, st you post e ahypotheses for pathology, biomechanical contributing factors, contraindications/precautions, prognosis, and management

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Cervical Spine Applied Anatomy

Jason Zafereo, PT, OCS, FAAOMPTCli i l O th di R h bilit ti Ed tiClinical Orthopedic Rehabilitation Education

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Objectives

Apply key concepts from the cervical anatomy/kinesiology self-study to aid in differential diagnosis for the following:– Headache – Cervical radiculopathy/myelopathy– Cervical disc and joint disorders– Cervical “instability”y

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HEADACHE

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M l k l l i f dMusculoskeletal pain referred to TCN from structures innervated by the C1-3 spinal nerves y p

• Upper cervical synovial joints (esp. C2-3)

• Upper cervical muscles• C2-3 disc• Dura mater of upper SC and

posterior cranial fossaP i i h i d i hibi dPain either perceived or inhibited based on higher center activity

• Cortex• Brainstem

10Boyling et al., Grieve's Modern Manual Therapy: The Vertebral Column, 2005; Bogduk, N Curr Pain Headache Rep, 2001

Differential Diagnosis of Headache (IHS)

Primary HeadachesTension t pe

Secondary H d h– Tension-type

– Migraine– Cluster

E ti l

Headaches– Trauma– Vascular

– Exertional

Other Headaches– Neuralgias

Vascular– Intracranial– Substance/Withdrawal

I f tig– Central Facial Pain

– Infection– Homeostasis– Cervical/Cranial– Psychiatric

11Mixed headache types are common with sensitization of TCN!!

Migraine Headache (IHS)

Headache attacks lasting 4-72 hours (untreated or unsuccessfully

Aura consisting of at least one of the following, but no motor ( y

treated) Headache has at least two of the

following characteristics:

gweakness:

– fully reversible visual symptoms including positive features (eg, flickering lights spots or lines)

– unilateral location– pulsating quality– moderate or severe pain intensity

aggravation by or causing

flickering lights, spots or lines) and/or negative features (ie, loss of vision)

– fully reversible sensory symptoms including positive features (ie pins– aggravation by or causing

avoidance of routine physical activity

During headache at least one of the

including positive features (ie, pins and needles) and/or negative features (ie, numbness)

– fully reversible dysphasic speech di t bfollowing:

– nausea and/or vomiting – photophobia and phonophobia

disturbance

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Cluster Headache (IHS)

Severe or very severe unilateral orbital, supraorbital and/or

Attacks have a frequency from one every other day to 8 per day p

temporal pain lasting 15-180 minutes if untreated

Headache is accompanied by at l t f th f ll i

y y p y

least one of the following: – ipsilateral conjunctival injection

and/or lacrimation – ipsilateral nasal congestion p g

and/or rhinorrhea – ipsilateral eyelid edema – ipsilateral forehead and facial

sweatingsweating – ipsilateral miosis and/or ptosis – a sense of restlessness or

agitation 13

Occipital Neuralgia (IHS)

Paroxysmal stabbing pain, with or without persistentwith or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third goccipital nerves

Tenderness over the affected nerve

Pain is eased temporarily by local anesthetic block of the nerve

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Dx Secondary HeadachesDx Secondary HeadachesMert et al, J Headache Pain 2008

‘‘Red flags’’ for secondary disordersS dd t f h d h– Sudden onset of headache

– New onset of headache with aura– Onset of headache after 50 years of age– Increased frequency or severity of headache– New onset of headache with an underlying medical condition– Headache with concomitant systemic illnessHeadache with concomitant systemic illness

Patients presenting to ER with headache– Presence of comorbidity– Patient’s age > 50– Existence of trigger factor– * 9.3 fold increased risk of secondary HA15

RADICULOPATHY/MYELOPATHY/

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Differential Diagnosis

Tension event associated withassociated with herniated intervertebral disc

Compression event Compression event associated with degenerative disc changeschanges

– Zygapophyseal joint– Uncovertebral joint– Ligamentum flavum

Sizer et al, Pain Practice, 200117

Soft Herniation

Degeneration occurs from the inside to outside (similar to (lumbar discs)

Most common C5/6 – C7/T1 Irritated posterior longitudinal

ligament leads to neck and arm pain

Acute torticollis positional faultP i ith itt l l Pain with sagittal plane movements

Treatment focused on axial decompressiondecompression

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Hard Herniation

Degeneration occurs from the outside to insideoutside to inside

Most common C2/3 – C4/5– Smallest A/P diameter and

highest uncinate processes C4-6 (Ebraheim et al, Clin Orthop Rel Res, 1997)

IVF stenosis creates isolated arm painPain with foraminal closing Pain with foraminal closing

Treatment focused on A/P decompression19

LOCAL CERVICAL SPINE PAIN: DISC VS JOINT

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Directional Preference vs Directional Preference vs Centralization

Centralization (CEN)M t f di t d

Prevalence in neck pain4 (CEN) 7 (DP)– Movement of radiated

pain towards the midline of the spine. Pain may actually increase at the

– .4 (CEN); .7 (DP)– Young and fewer

comorbidities more likely CENactually increase at the

spine.

Directional preference (DP)

CEN– DP associated with acute

sx and greater i t i f ti l(DP)

– Decrease in symptom intensity, CEN, or

improvement in functional outcome

– Neither CEN nor DP associated ith painimprovement in ROM

associated with a movement.

associated with pain outcomes

Edmond et al, 201421

Centralization (CEN)

McKenzie theory of CEN (Stevens and McKenzie(Stevens and McKenzie 1988)

– Alteration of gelatinous nucleus position through loading of IVD

– Requires intact annulus

Alternate mechanism for effectiveness in cervical spine possiblyspine, possibly neurophysiological (Mercer and Jull 1996)22

Differential Diagnosis

Soft disc herniationPositive dural tension testing– Positive dural tension testing

Degenerative disc disease– Reduced cervical lordosis

P i ith 3 D ti t ti l d– Pain with 3-D motion testing uncoupled Joint

– Pain with 3-D motion testing coupled– Zygapophyseal

Primary restriction into rotation– Uncovertebral

Primary restriction into sidebending

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INSTABILITY

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Pathophysiology

Degeneration and mechanical injury causesmechanical injury causes (Panjabi, J Spinal Disord, 1992)

– Poor postureR titi ti l t– Repetitive occupational trauma

– Acute trauma– Weakness of cervical

musculaturemusculature

Increase in neutral zone of a spinal segment

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Pathophysiology

Healthy versus microtrauma versusmicrotrauma versus macrotrauma (Jull et al 2004)

E i SCM ti ti– Excessive SCM activation in trauma groups during Craniocervical flexion

Chronic neck pain (Falla 2004)

– Decreased deep neck flexor activation with SCM overactivation

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Cervicothoracic Musculature

Global musclesUpper trapezius/Levator– Upper trapezius/Levator

– Splenius capitis/cervicis– Semispinalis capitis

SCM– SCM– Scalenes

Local muscles– Semispinalis cervicis– Multifidus– Longus colli/capitis (deep– Longus colli/capitis (deep

neck flexors)

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Differential Diagnosis

Directional Susceptibility to Movement (DSM)Movement (DSM)– Uni-planar motion

Extension Flexion Rotation

Combined motion– Combined motion Extension-Rotation

– Most common syndrome (Sahrmann 2011)(Sahrmann 2011)

Flexion-Rotation28

Extension DSM

History of whiplashOld ti t Older patient

Forward head/Increased thoracic kyphosiskyphosis

Pain/Hinge point with cervical extension

Weak DNF/Thoracic extensors Stiffness thoracic extension, SCM,

scalenescalene

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Flexion DSM

Exaggerated “correct” posture Younger patient Flat thoracic spine Pain with cervical flexion Weak intrinsic neck extensors Stiffness DNF and thoracic

flexion

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Rotation DSMSahrmann 2002

Scapula determines asymmetrical rotation forces on neckrotation forces on neck

– Levator rotates neck ipsilateral – Upper trap rotates neck

contralateral Pain/clicking during

rotation/sidebend Most common scapular impairment Most common scapular impairment

– Scapular downward rotation – Scapular depression– Tight: Levator Rhomboid Pec– Tight: Levator, Rhomboid, Pec

minor, Lats– Weak: Serratus, Lower trap,

*Upper trap31