Learning Objec&ves. Evalua&on and Management of Posterior Neck Pain 4/8/15. Incidence of Neck Pain

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1 Learning Objec&ves Evalua&on and Management of Posterior Neck Pain James J. Lehman, DC, MBA, FACO Associate Professor of Clinical Sciences University of Bridgeport College of Chiroprac&c Correlate anatomy and the pa&ents signs and symptoms of neck pain in order to locate the neuromusculoskeletal lesion. Enable differen&al diagnosis of neck pain Elicit a focused neuromusculoskeletal pa&ent history for neck pain. Provide Evidence- based and pa&ent- centered evalua&on procedures. Organize a clinical thought process while performing an orthopedic examina&on. Iden&fy injured and painful &ssues through careful assessment and intelligent use of orthopedic tes&ng. Neck pain is an almost universal human condi&on and is among the most common complaints presented to family physicians. Alan B. Douglass, MD, and Edward T. Bope, MD Evalua&on and Treatment of Posterior Neck Pain in Family Prac&ce. JABFP November December 2004 Vol. 17 Supplement Incidence of Neck Pain 10% of people will have neck pain in any given month 1% of all visits to primary care Cervical Anatomy Cervical Anatomy 1

2 4/8/15 Key to Success Diagnosis is the key to successful treatment! Differen&al Diagnosis Biomechanical Causes Axial Neck Pain Whiplash Associated Disorder Radiculopathy Cervical Myelopathy Infec&on Neoplasm Axial Neck Pain The result of the complex interac&on of muscular and ligamentous factors related to posture, sleep habits, ergonomics such as computer monitor and bifocal posi&on, stress, chronic muscle fa&gue, postural adapta&on to other primary pain sources (shoulder, temporomandibular joint, craniocervical), or degenera&ve changes of the cervical discs or facet joints. Alan B. Douglass, MD, and Edward T. Bope, MD Evalua&on and Treatment of Posterior Neck Pain in Family Prac&ce. JABFP November December 2004 Vol. 17 Supplement Axial Neck Pain Axial neck pain is the most common cause of neck pain and has a high rate of spontaneous resolu&on. 2

3 Whiplash Associated Disorder Is a special case of acute or subacute neck pain resul&ng from accelera&on/decelera&on transfer of energy to the neck. Alan B. Douglass, MD, and Edward T. Bope, MD. Evalua&on and Treatment of Posterior Neck Pain in Family Prac&ce. JABFP November December 2004 Vol. 17 Supplement Whiplash Associated Disorder Mul&ple pain generators are usually involved, including myofascial, ligamentous, discogenic, and facet joint sources. It most commonly occurs in rear- end motor vehicle crashes, but can occur from other causes, such as diving injuries. Whiplash Associated Disorders (WAD) In the United States, 1 million cases of WAD occur annually as a result of motor vehicle accidents. Evans RW. Some observa&ons of whiplash injuries. Neurol Clin 1992;10: Cervical Radiculopathy Is motor and/or sensory changes in the neck and arms resul&ng from extrinsic pressure on a cervical nerve root, usually by osteophytes or disk material. Radhakrishnan K, Litchy WJ, O Fallon WM, Kurland. LT. Epidemiology of cervical radiculopathy. A popula&on- based study from Rochester, Minnesota, Brain 1994;117: Cervical Radiculopathy The pathology underlying the symptoms is heterogeneous. Seventy to ninety percent of cases are associated with foraminal encroachment by degenera&ve bony changes; herniated disk material is present in most of the remainder. Myelopathy Is the manifesta<on of long tract signs resul&ng from a decrease in the space available in the cervical canal for the spinal cord. Rao R. Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology, natural history, and clinical evalua&on. J Bone Joint Surg Am 2002; 84:

4 Myelopathy A number of factors contribute to extrinsic pressure, including the congenital cord diameter, osteophytes, protruding disk material, dynamic changes in canal diameter and the cord itself, and the vascular supply to the cord. A Call to Revolu&onize Chronic Pain Care in America: An Opportunity in Health Care Reform The Mayday Fund 2009 Chronic Pain Treatment Most people in pain, including those with chronic symptoms, go to primary care providers to get relief. - current systems of care do not adequately train or support internists, family physicians and pediatricians, the other health care providers who provide primary care in mee&ng the challenge of trea&ng pain as a chronic illness. Coordina&on of Chronic Pain Care It is an unusual pa&ent who has access to coordinated interdisciplinary therapy for ongoing pain symptoms. Chronic Pain Care Instead of receiving effec&ve relief, pa&ents with persistent pain ohen find themselves in an endless cycle, seeing mul&ple health care providers, including many specialists in areas other than pain, who are not prepared to respond effec&vely. 4

5 Primary care providers ohen receive lijle training in the assessment and treatment of complex chronic pain condi&ons. Chronic Pain Care They tend to work under condi&ons that permit lijle &me with each pa&ent and few op&ons for specialist referrals. Chronic Pain Care Historically, the health care system has failed to recognize chronic pain as a legi&mate condi&on. However, it is clear that persistent pain is a complex illness that has many causes and affects every part of life, and in the process, exacts enormous social costs. Chronic Pain Cervical Spine Assessment Protocol History Observa&on Physical examina&on Inspec&on Palpa&on Range of mo&on Orthopedic maneuvers/special tests James J. Lehman, DC, MBA, DABCO History of Present Illness History Taking and Observa&on The L, M, N, O, P, Q, R, S, T process is suggested for all pa&ents presen&ng with neuromusculoskeletal condi&ons. Rust s sign Dejerine s sign Bakody s sign Lhermije s sign 5

6 Inspec&on Observa&on of behavior Posture Body movements Gait Speech Rust s Sign May grab head upon removal of cervical collar May use hand to lih head when rising from supine posi&on Bakody s Sign Sign of cervical radiculopathy Lhermi?e s Sign Cervical myelopathy Mul&ple Sclerosis Orthopedic Palpa&on Cervical Range of Mo@on Tes@ng Sta&c palpa&on Flat palpa&on Superficial Deep Flexion Extension Rota&on (R/L) Lateral Flexion (R/L) 6

7 Range of Mo&on Evalua&on Ac&ve, Passive and Restricted Range of Mo&on Evalua&on Ac&ve, Passive and Restricted Check Symmetrical Free of restric&on or aberrant mo&on Pain free or provoca&ve movement Crepita&on checked first General and least specific Passive tests for ligament damage tests for muscle damage Passive and resis&ve for involved joints only. James J. Lehman, DC, MBA, DABCO James J. Lehman, DC, MBA, DABCO Orthopedic Test A provoca&ve maneuver (most ohen) involving stretching, contrac&ng or compressing of &ssues in order to duplicate the pa&ents pain and iden&fy the involved &ssues. Orthopedic Maneuvers Anatomical structure tests Dural tension Foraminal canal patency Spinal canal patency Ligamentous Muscle Tendon James J. Lehman, DC, MBA, DABCO O Donoghue s Maneuver First cervical special test recorded following range of mo&on tes&ng. Valsalva Maneuver First special test performed for spine condi&ons Valsalva maneuver for IVD syndrome or tumor (space occupying lesion) 7

8 Shoulder Abduc&on Test or Arm Eleva&on Test Bakody s sign for nerve root irrita&on is also known as Abduc&on Relief Sign Cervical Compression Tests Foraminal compression (passive) Jackson s Spurling s (in favor) Extension/Flexion Cervical Compression Tests Posterior Cervical Compression Posi&ve findings all indicate radicular pain Imbrica&on of zygapophyseal joints with increased pain Reduc&on of HNP and pain Cervical Distrac&on Test Shoulder Depression Test Distrac&on test for nerve root, facet, or myospasm Posi@ve test relieves pain Nega&ve test increases pain Contralateral neck/ arm pain indicates nerve root or joint Ipsilateral cervical/ shoulder pain indicates muscle 8

9 4/8/15 Mo&on Radiography MRI Primum Non Nocere CT scan showing C5 pedicle and facet fracture. James J. Lehman, DC, MBA, DABCO ICD 9 Codes Key to Success Axial Neck Pain Whiplash Associated Disorder Post- trauma&c Chronic Pain Cervical Radiculopathy Cervical Myelopathy Diagnosis is the key to successful treatment! 9