Cervical Case Study. M. Benson, A. Felts, S. Kibiloski, J. Mowen, A. Rijhwani

Transcription

1 Cervical Case Study M. Benson, A. Felts, S. Kibiloski, J. Mowen, A. Rijhwani

2 Medical Dx 35 y.o. female with myofascial pain No significant radiological findings other than reported flattened cervical spine, mild scoliosis by chiropractor No precautions given by physician

3 Subjective History CC: Unrelenting L neck and shoulder pain with paresthesia into L third finger L arm weakness MOI: 2 months prior: - high stress - increased neck discomfort and neck muscle tightness One week ago: - pt. made a sudden movement to catch son - felt sudden lock down in neck afterwards

4 Subjective History Current symptoms: L neck & mid scap pain Intermittent parasthesias into 3rd finger. Pain: Current - 8/10, Low - 5/10, High - 10/10 PMH Anxiety Depression Mild scoliosis Birth of 2 children

5 Subjective History Medications Name Dosage Indication Wellbutrin 150 mg, 24 hr. tablet Antidepressant Citalopram 40 mg Antidepressant (SSRI) Diazepam 4 mg, 4x/day as needed Anti-anxiety (Benzo) Naproxen 500 mg, 2x/day NSAID

6 Objective Exam Posture Tall and thin R handed Elevated L shoulder, scapula, and 1st rib L thoracic convexity Forward head and mild increased thoracic kyphosis Normal lordosis

7 Objective Exam Cervical ROM: Flexion: 55º, discomfort, concordant symptoms (normal: 50º) Extension: 60º, pinching on L (normal: 60º) Rotation: L - 60º, pinch on L; R - 68º (normal: 80º) Sidebend: L - 40º, pain; R - 45º (normal: 45º) UE ROM: WNL B in: Flexion, ER, IR Strength: 4/5 in L Shoulder: Flexion, Abduction, Biceps, Triceps, Brachioradialis, Wrist extensors 5/5 in RUE mm

8 Objective Exam Palpation Tenderness with trigger points in: - L scalenes - L levator scapula - L upper and middle trap - L upper cervical region Joint Mobility Hypermobile body type Hypomobility on L C 2/3, 5/6, 6/7, & T1 L rotation in L upper thoracic region Hypomobility in L thoracic to PA spring

9 Special Tests ULTT Positive for median and radial nerve Cervical Distraction Positive for symptom relief Spurlings Positive with symptom reproduction

10 Outcome Measures NDI 25/50 MDC: 5 points 0-4 = no disability 5-14 = mild = moderate = severe above 34 = complete SPADI Pain - 66% Disability - 55% Total disability for L shoulder - 59% MDC: 10% No disability= 0

11 Patient Problems CCU nurse: heavy lifting, reaching, shifting of patients, 12 hour long shifts 2 small children: carrying, lifting, and care of children PMH Anxiety and depression exacerbate symptoms of pain and limit ability to relax upper quarter heightening muscle tension

12 Patient Goals 1. Pt. wants to return to work and work at computer without pain 2. Pt. wants to be able to pick up children without weakness or pain 3. Pt. wants to have L UE strength return to normal

13 ICF Model

14 Differential Dx Cervical Radiculopathy Cervical Facet Syndrome Thoracic Outlet Syndrome - Deep stabbing, burning neck pain - Pain, numbness, or tingling in UE - UE weakness - AGGs: prolonged sitting/reading, external or lateral rotation of spine - EASEs: supine with head and neck supported - Pain with extension and rotation, often bilateral - Pain can be gradual or acute following a traumatic incident - Posterior neck stiffness - Cervicogenic headache - Possible pain referral to shoulder, scapular regions, and UE - Often also complain of lumbar facet problems - Pain and heaviness in the cervical region and arms - Paresthesias (medial side of arm) - Aggravated by overhead positioning of the arms - Intrinsic muscle deficit/atrophy of hand - Easy fatigability, paleness, or coldness of hand - Pain with activity - Deep, boring, toothache-like pain - Cold intolerance - Loss of dexterity - Waking from sleep with pain and numbness

15 PT Evaluation C7 Cervical Radiculopathy Irritation of the nerve root caused by compression or inflammation Symptoms can radiate into the arm and hand C7 - causes pain &/or weakness to hand, can include: - Triceps - middle finger

16 Diagnostic Question What combination of tests is most accurate for diagnosing cervical radiculopathy in a 35 year-old woman with neck pain and radiating symptoms?

17 A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy Rubinstein et. al, European Spine Journal, 2007

18 A Systematic Review of Cohort Studies: Level 2a Evidence Purpose To determine diagnostic accuracy of clinical provocative tests of the neck that are commonly used in clinical practice for patients suspected cervical radiculopathy Methodological criteria Evaluated using QUADAS to determine any bias in diagnostic research such as spectrum bias, disease progression bias, review bias, etc.

19 Methods Inclusion Criteria Inclusion of any provocative test of neck for diagnosing cervical radiculopathy, use of reference standard, sensitivity and specificity reported or could be (re)calculated, full report Exclusion Criteria Case series or case reports, any animal, surgical, and cadaveric studies

20 Results Sensitivity (rule out) Specificity (rule in) Low Moderate High Low Moderate High Spurling s Traction/ distraction Valsalva ULTT Shoulder abduction

21 Conclusions Conclusions: A positive Spurling's, traction/distraction, and Valsalva might suggest cervical radiculopathy (high specificity) A negative ULTT might rule out (high sensitivity) Values of tests should be interpreted with caution if no other clinical info or evidence Limitations: Only 6 studies No study used optimal reference standard Lack of standardization or performance of tests

22 Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy Wainner et al. SPINE, 2003

23 A Blinded, Prospective Diagnostic Test Study: Level 2b Evidence Purpose: Assess individual items and identify optimum test-item cluster 82 patients recruited from four medical facilities Inclusion Criteria: electrophysiologic lab testing suggests CR or CTS Exclusion Criteria: systemic disease, bilateral pain, surgical procedures, history adversely affecting function of UE, previous testing on symptomatic limb NCS and EMG - reference standard Standardized clinical assessment of 34 items Performed by two therapists blinded to EMG/NCS results to test reliability

24 Analysis 11 variables with acceptable diagnostic accuracy ULTT A, Cervical rotation < 60, Cervical flexion < 55, Biceps MSR, Distraction test, Bicep MMT, Valsalva test, Spurling test A, Shoulder abduction test, C5 sensation, asking where symptoms are most bothersome, and asking if moving or positioning neck improves symptoms Regression model determined the best CR test item cluster

25 Conclusion Conclusions Test Item Cluster identified that provides higher posttest probability changes than individual items Limitations Reference standard required minimum EMG findings to establish diagnosis Large number of examiners and locations Study sample represented mild cases of almost exclusively C6 and C7 root level Further Research Tool requires validation with larger sample size

26 Conclusion What combination of tests is most accurate for diagnosing cervical radiculopathy in a 35-year old woman with neck pain and radiating symptoms? Cervical Distraction, Spurling s, Cervical Rotation, ULTT 1

27 Intervention Question For a 35-year old woman with cervical radiculopathy, is therapeutic exercise in conjunction with manual therapy more effective at reducing disability and symptoms compared to manual therapy alone?

28 Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review Boyles et al. Journal of Manual and Manipulative Therapy, 2011

29 A Systematic review: Level 2a evidence Purpose No systematic reviews have investigated the use of manual physical therapy for treatment of cervical radiculopathy. Objective To review current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy.

30 Methods Inclusion Criteria English language, PEDro score > 5 RCTs level I through case series (level IV) in peer reviewed journals between 1995 and Feb 2011 Patient under care of PT treated w/ manual therapy Diagnosed w/ CR based on MRI, CT Myelography, or a positive finding according to Wainner et al. CPR with 3 of 4 items present Included at least one of the following outcome measures AROM, PROM, functional outcome measure specific to neck (NDI), a quality of life measure (GROC) and a pain measure. Exclusion Criteria Surgical intervention within 1 year Non PT manual procedures Use of cervical collars and mechanical traction

31 Article Intervention Result Mobilization Manipulation Neural Mob MET Ragonese et al. Manual + Therapeutic exercise lowest pain and disability scores. Young et al. Significant improvements in pain and disability. Cleland et al. 53% surpassed MCIC Persson et al. No btw group difference

32 Conclusion Manual + Therapeutic Exercise = BEST Which intervention is responsible?? Future high quality RCTs featuring control groups needed.

33 Limitations 1. Only one article specifically prescribed the performed intervention. The other three articles allowed the PT to determine appropriate treatment. 2. None of the included studies were RCTs, so determining cause and effect relationship between manual therapy and the relief of CR symptoms is difficult. 3. Only articles published in English were reviewed leading to possible exclusion of other relevant articles.

34 A Randomized Control Trial Comparing Manual Therapy to Therapeutic Exercises, to a Combination of Therapies, for the Treatment of Cervical Radiculopathy Ragonese, Orthopedic Practice, 2009

35 A Randomized Control Trial: Level 1b Evidence Purpose: To determine which treatment method will produce superior outcomes for patients with cervical radiculopathy: manual physical therapy, therapeutic exercises, or a combination of manual physical therapy and therapeutic exercises

36 Methods: 30 patients with cervical radiculopathy 3 treatment groups: Only manual therapy Only therapeutic exercises Both manual therapy and therapeutic exercises 3 sessions/week for 3 weeks

37 Methods: Outcome Measures: Assessed at initial session, once per week, and at final session Numeric Pain Rating Scale (NPRS) Neck Disability Index (NDI) Cervical rotation AROM Results analyzed using independent groups ANOVA

38 Participant Characteristics 30 patients who were referred to the Outpatient Physical Therapy Department at Loyola University Medical Center with a chief complaint of neck and/or UE symptoms Inclusion Criteria: 4 positive exam findings on CPR of clinical radiculopathy Exclusion Criteria: If patient had any current medical condition that placed their rehab outside of routine practice

39 Intervention: Manual group: Cervical lateral glides Thoracic mobilizations Median nerve gliding Exercise group: Deep neck flexor strengthening Lower and middle trapezius strengthening Serratus anterior strengthening Combination group: Both manual therapy and therapeutic exercises

40 Results All 3 groups demonstrated significant improvements in pain, with the combination group showing greatest results All 3 groups demonstrated significant improvements in function, with the combination group again showing the greatest results All 3 groups demonstrated equal improvements in cervical rotation

41 Conclusion A multimodal treatment approach is superior than either intervention alone Combination of manual therapy and strengthening exercises

42 Limitations Small sample size Although only one evaluator, different therapists providing treatment (although were trained on each of manual techniques) There was no long-term follow-up to see how long patients improvement lasted The combination group essentially received 2x the amount of therapy

43 Conclusion For a 35-year old woman with cervical radiculopathy, is therapeutic exercise in conjunction with manual therapy more effective at reducing disability and symptoms compared to manual therapy alone? YES

44 Class Goal & Intervention

45 Physical Therapy Goals Short Term (3 weeks) Pt will demonstrate full active cervical flexion and rotation with pain < 3/10 to return to functional ADLs. Pt will score 15/50 on NDI for decreased perceived disability. Pt will report ability to work at computer for 15 minutes asymptomatically with proper body mechanics in order to return to function and work activities.

46 Physical Therapy Goals Long term (6 weeks) Pt will demonstrate ability to lift 40 lbs asymptomatically with proper body mechanics in order to return to childcare activities. Pt will demonstrate the ability to reach behind back asymptomatically in order to perform ADLs independently. Pt will score 5/50 on NDI for decreased perceived disability.

47 Pain Relief

48 Education

49 Strengthening

50 Manual & Stretching

51 References 1. Boyles, R. et al Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. Journal of Manual and Manipulative Therapy, Ragonese, J. et al A Randomized Control Trial Comparing Manual Therapy to Therapeutic Exercises, to a Combination of Therapies, for the Treatment of Cervical Radiculopathy. Orthopedic Practice, Rubinstein, S, M. et al A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. European Spine Journal, Wainer, R. S. et al.,2003. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. SPINE,

52 Questions?