Pre-Course Review. Jason Zafereo, PT, OCS, FAAOMPT

Transcription

1 Pre-Course Review Jason Zafereo, PT, OCS, FAAOMPT Clinical i l Orthopedic Rehabilitation ti Education 1

2 Objectives Review key concepts from history-taking, examination, and treatment self-studies Apply a hypothesis-testing framework to critically reason through orthopedic patient cases 2

3 History-taking 3 Data collection and hypothesis formation Subjective exam History of present illness Onset, Location, Nature, Aggravating/easing, Intensity, Associated symptoms, Timing Functional status Medical History Co-morbidities, radiology, prior treatment, patient goal(s)

4 Examination and Treatment 4 Hypothesis testing during objective exam and treatmentt t Objective exam Impairment: ROM, Palpation for position, Flexibility, MMT Pathology: ROM, Palpation for condition, Neurological exam, Special testing, Resisted testing Treatment Pain, Stiffness, Weakness

5 Critical Reasoning 5 Hypothesis categories Pathology Contractile/non-contractile Contributing factors Environmental, Behavioral, Emotional, Physical, Biomechanical Contraindications/precautions Prognosis Co-morbidities, Flags, Healing phase, Exam findings Management Yellow flags, Pain, Stiffness, Weakness, Education

6 Case Practice 6 Read the information immediately under SUBJECTIVE for Case 4 List 2-3 pre-history pathology hypotheses and ~5 subjective findings you would expect to have for each Read the history and attempt to make the features fit your hypotheses Narrow your hypothesis list and make a list of the ~3 confirming tests you would like to see in your exam for each Read the exam and attempt to make the features fit Change hypotheses as needed Finally, list your post-exam hypotheses for pathology, biomechanical contributing factors, contraindications/precautions, prognosis, and management

7 Cervical Spine Applied Anatomy Jason Zafereo, PT, OCS, FAAOMPT Clinical i l Orthopedic Rehabilitation ti Education 7

8 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 8

9 9 HEADACHE

10 Musculoskeletal l lpain referred to TCN from structures innervated by the C1-3 spinal nerves Upper cervical synovial joints (esp. C2-3) Upper cervical muscles C2-3 disc Dura mater of upper SC and posterior cranial fossa Pi Pain either ih perceived or inhibited ihibi based on higher center activity Cortex Brainstem Boyling et al., Grieve's Modern Manual Therapy: The Vertebral Column, 2005; 10 Bogduk, N Curr Pain Headache Rep, 2001

11 Differential Diagnosis of Headache (IHS) 11 Primary Headaches Tension-type Migraine Cluster Exertional Other Headaches Neuralgias Central Facial Pain Secondary Headaches Trauma Vascular Intracranial Substance/Withdrawal Infection Homeostasis Cervical/Cranial Psychiatric Mixed headache types are common with sensitization of TCN!!

12 Migraine Headache (IHS) 12 Headache attacks lasting 4-72 Aura consisting of at least one of hours (untreated or unsuccessfully the following, but no motor treated) weakness: Headache has at least two of the fully reversible visual symptoms following characteristics: including positive features (eg, flickering lights, spots or lines) unilateral location and/or negative features (ie, loss pulsating quality of vision) moderate or severe pain intensity fully reversible sensory symptoms aggravation by or causing including positive features (ie, pins avoidance of routine physical activity and needles) and/or negative features (ie, numbness) During headache at least one of the following: fully reversible dysphasic speech disturbance nausea and/or vomiting photophobia and phonophobia

13 Cluster Headache (IHS) 13 Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting minutes if untreated Headache is accompanied by at least one of the following: ipsilateral conjunctival injection and/or lacrimation ipsilateral nasal congestion and/or rhinorrhea ipsilateral eyelid edema ipsilateral forehead and facial sweating ipsilateral miosis and/or ptosis a sense of restlessness or agitation Attacks have a frequency from one every other day to 8 per day

14 Occipital Neuralgia (IHS) Paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third occipital nerves Tenderness over the affected nerve Pain is eased temporarily by local anesthetic block of the nerve 14

15 Dx Secondary Headaches Mert et al, J Headache Pain Red flags for secondary disorders Sudden onset of headache h 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 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 HA

16 16 RADICULOPATHY/MYELOPATHY

17 Differential Diagnosis Tension event associated with herniated intervertebral disc Compression event associated with degenerative disc changes Zygapophyseal joint Uncovertebral joint Ligamentum flavum 17 Sizer et al, Pain Practice, 2001

18 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 fault Pain with sagittal plane movements Treatment focused on axial decompression 18

19 Hard Herniation 19 Degeneration occurs from the outside 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 pain Pain with foraminal closing Treatment focused on A/P decompression

20 20 LOCAL CERVICAL SPINE PAIN: DISC VS JOINT

21 Directional Preference vs Centralization 21 Centralization (CEN) Movement of radiated d pain towards the midline of the spine. Pain may actually increase at the spine. Directional preference (DP) Decrease in symptom intensity, CEN, or improvement in ROM associated with a movement. Prevalence in neck pain.4 (CEN);.7 (DP) Young and fewer comorbidities more likely CEN DP associated with acute sx and greater improvement in functional outcome Neither CEN nor DP associated with pain outcomes Edmond et al, 2014

22 Centralization (CEN) 22 McKenzie theory of CEN (Stevens and McKenzie 1988) Alteration of gelatinous nucleus position through loading of IVD Requires intact annulus Alternate mechanism for effectiveness in cervical spine, possibly neurophysiological (Mercer and Jull 1996)

23 Differential Diagnosis Soft disc herniation Positive dural tension testing Degenerative disc disease Reduced cervical lordosis Pain with 3-D motion testing ti uncoupled Joint Pain with 3-D motion testing coupled Zygapophyseal Primary restriction into rotation Uncovertebral Primary restriction into sidebending 23

24 24 INSTABILITY

25 Pathophysiology Degeneration and mechanical injury causes (Panjabi, J Spinal Disord, 1992) Poor posture Repetitive occupational trauma Acute trauma Weakness of cervical musculature Increase in neutral zone of a spinal segment 25

26 Pathophysiology 26 Healthy versus microtrauma versus macrotrauma (Jull et al 2004) Excessive SCM activation in trauma groups during Craniocervical flexion Chronic neck pain (Falla 2004) Decreased deep neck flexor activation with SCM overactivation

27 Cervicothoracic Musculature 27 Global muscles Upper trapezius/levator Splenius capitis/cervicis Semispinalis capitis SCM Scalenes Local muscles Semispinalis cervicis Multifidus Longus colli/capitis (deep neck flexors)

28 Differential Diagnosis 28 Directional Susceptibility to Movement (DSM) Uni-planar motion Extension Flexion Rotation Combined motion Extension-Rotation Most common syndrome (Sahrmann 2011) Flexion-Rotation

29 Extension DSM History of whiplash Older patient t Forward head/increased thoracic kyphosis Pain/Hinge point with cervical extension Weak DNF/Thoracic extensors Stiffness thoracic extension, SCM, scalene 29

30 Flexion DSM Exaggerated correct posture Younger patient Flat thoracic spine Pain with cervical flexion Weak intrinsic neck extensors Stiffness DNF and thoracic flexion 30

31 Rotation DSM Sahrmann Scapula determines asymmetrical rotation forces on neck Levator rotates neck ipsilateral Upper trap rotates neck contralateral Pain/clicking during rotation/sidebend Most common scapular impairment Scapular downward rotation Scapular depression Tight: Levator, Rhomboid, Pec minor, Lats Weak: Serratus, Lower trap, *Upper trap