WEEKEND 1 CERVICAL SPINE

Transcription

1 Virginia Orthopedic Manual Physical Therapy Institute - Technique Manual WEEKEND 1 CERVICAL SPINE Cervical Active Range of Motion Testing Rotation CT Flexion Mid Cervical Flexion Extension Side-Bending

2 - Patient Positioning: Seated at edge of bed, feet on the floor, appropriately undressed, in their normal posture at first and then corrected to compare if necessary, eyes open to monitor vertebrobasilar system - Therapist Positioning: Standing in front or side to be able to assess quality of motion, be able to monitor eyes (especially with rotation and quadrant positioning) for possible VBI symptoms. Hands placed in appropriate positions to apply resistance and overpressures when indicated - Indications: Completed as part of initial scan (active, passive, and resisted testing). Attempt to discern type of tissue at fault articular, contractile vs non-contractile. - Contraindications: VBI, UC stability, Red Flag concern including fracture, high level of irritability (may only test 1 or 2 motions pending their SINNS) o Allow patient to move in their natural posture, without cuing first o Observe both quality and quantity, where is the movement occurring? o Observe for compensation strategies Flexion: CV region in extension, jaw opening SB: rotation, shoulder shrug Rotation: SB, thoracic rotation, flexion of mid cervical Extension: CV extension and CTJ flexion o Utilize overpressures when appropriate assessing quality, quantity, end feel, and questioning symptom provocation o Change posture and reassess movements, does it change? o CT Flexion often symptomatic but not restricted o Rotation < 60 degrees is one test item found in clinical prediction rule for cervical radiculopathy as per Wainner, et al. o Reassess a provocative AROM with scapular elevation to differentiate soft tissue component to symptoms o May require sustained positioning with overpressures to simulate weight bearing sensitive symptoms o Rotation and SB limited to same side = possible mid-cervical restriction o Rotation and SB limited to opposite side = possible upper-cervical restriction

3 Cervical Active Range of Motion Testing Combined Motions Extension + L SB Flexion + L SB - Patient Positioning: Seated at edge of bed, feet on the floor, appropriately undressed, eyes open to monitor vertebrobasilar system - Therapist Positioning: In front of patient, able to monitor eyes and communicate with patient regarding their symptoms and monitor any red flag concerns - Indications: Full straight plane AROMs without symptom provocation. Combined ROMs utilized in attempt to progressively load structures with increased vigor in attempt to provoke symptoms. Ext + Ipsilateral SB places the ipsilateral facets in full extension while Flexion + Contralateral SB places the ipsilateral facets in full flexion. - Contraindications: VBI, UC stability, Red Flag concern including fracture, high level of irritability o May require sustained positioning to simulate weight bearing compressive force

4 Spurling s Maneuver/Test - Patient Positioning: Seated at edge of bed, feet on the floor, appropriately undressed, eyes open to monitor vertebrobasilar system - Therapist Positioning: The original test describes the therapist behind the patient in position where they can quickly and vigorously deliver compression through the head. However, we are proponents of being in front of the patient to view the eyes and response to this positioning as it challenges the vertebral artery as well as the foramen. Assisting the patient in and out of the position is also helpful as this test is often provocative. - Indications: Designed to test for cervical radiculopathy. Also a test item found in clinical prediction rule for cervical radiculopathy as per Wainner, et al. May be utilized as progression of testing following (-) response to AROM and Combined motion testing - Contraindications: VBI, UC stability, Red Flag concern, high level of irritability o Rather than a quick compressive impulse as the original test describe, we suggest gradual loading of compression in this quadrant position o Communication is key throughout the test to discern musculoskeletal symptoms from non-musculoskeletal or red-flag concerns o Recent study found most foraminal narrowing of C4/5 and C5/6 with Spurling s (up to 70% cross sectional area of controls)

5 Cervical Compression Testing - Patient Positioning: Seated at edge of bed, feet on the floor, appropriately undressed - Therapist Positioning: Standing behind the patient, arms tented over head with fingers interlocked and elbows resting on shoulders of patient. Downward compressive force is applied in attempt to provoke symptoms. - Indications: Provoke symptoms in a less irritable patient, possibly with discogenic symptoms or weight bearing insensitivity - Contraindications: VBI, UC stability, Red Flag concern including fracture, high level of irritability

6 Cervical Distraction Testing (Seated/Supine) Supine Distraction Distraction in Flexion Distraction in Extension - Patient Positioning: Seated at edge of bed, feet on the floor, appropriately undressed. Supine distraction tested with patient supine in comfortable resting position. - Therapist Positioning: Standing behind the patient, heels of hands placed under occiput with forearms resting on shoulders of patient. In supine hands cradle cervical spine around segment of interest where more specific distraction can be applied. - Indications: Utilized to decrease symptoms of possible discogenic or articular origin which appear weight bearing and compressive sensitive. May give an indication of type of treatment technique which may be effective. May also indicate tissue at fault. - Contraindications: VBI, UC stability, Red Flag concern, high level of irritability o Reduction of symptoms with distraction in flexion may indicate disogenic origin o Reduction of symptoms with distraction in extension may indicate facet/articular origin o 1 item found in clinical prediction rule for cervical radiculopathy as per Wainner, et al. (distraction in supine)

7 PA Provocation Testing Central PA Testing Unilateral PA Testing - Patient Positioning: Prone lying with face in cradle and forehead resting in palms of hands - Therapist Positioning: Standing at head end of bed, height of table approx at knee level, arms straight, thumbs together and placed on SP (for central) and articular pillar (for unilateral). Thumbs become passive observers as per Maitland as the motion is generated through the body, weight shifting and flexing operator s knees. Appreciate the end range if possible by taking 2-3+ passes to get to the end. - Indications: Completed as part of typical cervical examination, can be utilized as pain provocation technique, to assess neutral zone and amount of mobility present at a segment, as well as PAIVM testing (in the Australian/Maitland concept). This technique also translates well into treatment. - Contraindications: VBI, UC stability, Red Flag concern o Pain with PA spring testing recently found as 1 predictor of a cluster of findings associated with patients likely to benefit from cervical manipulation o Cervical spine positioning can be modified in attempt to find a most comparable sign or * (with addition of rotation, flexion, extension, upper cervical flex/ext)

8 Neurodynamic Testing (ULPT 1a Median Nerve Base Test) Patient Positioning: Supine on plinth, contralateral arm at side, head in neutral without a pillow if possible, LEs in neutral positioning. If irritability or situation dictates the cervical spine being on a pillow, make sure you re-assess in the same position to ensure reliability Therapist Positioning: Standing at side to be tested, using pistol grip grasping hand to control UE. Opposite hand made into fist placed above shoulder girdle to monitor response to testing (not depressing). Order of procedure Abd to 90 on PTs knee, ER to 90, full supination, full wrist/finger extension, elbow extension, cervical SB ipsilat/contra Indications: Test item for cervical radiculopathy cluster (most sensitive of tests at 97%), often assessed as part of typical cervical spine exam, especially when referred pain is present in attempt to determine dural component to symptoms Contraindications: Extreme irritability, lack of shoulder mobility necessary to achieve testing positions (CANCER?) Clinical Pearls: o Chad Cook presents the point that scapular depression is unnecessary since the test already has such strong Sn

9 o o o Test does not tell you area of neurodynamic restriction, however, SB towards and away will often decrease and increase symptoms respectively when a lengthening dysfunction is present. SB towards may increase the symptom if significant facet irritability is present. SB away may also decrease symptoms if there is dysfunction in a mechanical interface which the nerve being tested travels through. Often utilized as a comparable finding and objective * to reassess throughout progression of treatment Can be utilized during cervical side glide mobilization as well as with soft tissue techniques along the neurodynamic pathway as a way to increase vigor

10 PPIVMs Passive Physiologic Intervertebral Motion Testing - Patient Positioning: Supine, head on pillow, cervical spine in neutral flexion/extension - Therapist Positioning: Standing at head of plinth, cradling cervical spine with both hands at the articular pillars of the segment of interest. Contact points are radial border of 1 st MCP or PIP. To increase patient comfort and to minimize loss of force, contact may be made through the patient s forehead by the operator s chest/stomach. Sidebending at the level (and only the level of interest) is created with the ipsilateral hand (R side in picture above), while facilitated by contralateral side to further SB. Physiologic SB is assessed and taken through its full ROM (at that level) to assess amount of range and end feel. - Indications: Completed as part of typical cervical spine assessment. ROM loss indicates assessment of physiologic motions in attempt to determine cause of limitation (extra or intra-articular origin). - Contraindications: High levels of irritability, surgical fixation/fusion, fracture suspicion o Can assess any physiologic motion (flexion/extension/sb/rotation) o Assessment done in neutral if symptoms are provoked with straight plane testing o Assessment done in flexion or extension bias if symptoms are provoked in combined quadrant testing o Ideally testing 1 segment, in 1 direction, 1 at a time and comparing to opposite side of adjacent segments o Assessing quantity, quality of motion, end feel and looking for symptom provocation o Can become treatment if an extra-articular restriction is identified (PPIVM is positive for limitation but PAIVM is negative for limitation

11 PAIVMs Passive Accessory Intervertebral Motion Testing Neutral Flexion Extension - Patient Positioning: Supine, head on pillow, cervical spine in neutral, flexion or extension - Therapist Positioning: Standing at head of plinth, cradling cervical spine with both handsat the articular pillars of the segment of interest. Contact points are radial border of 1st MCP or PIP. PAIVM testing is completed after PPIVM assessment and from this same position, direction of force is an accessory glide directed medially, inferiorly and slightly posterior which assesses the segments ability to fully extend or close. Segmental mobility is compared to contralateral facet at the same level as well as adjacent segments.

12 - Indications: Completed as part of typical cervical spine assessment. PAIVM testing is completed if a limitation in PPIVM is identified. A restricted or stiff PAIVM with or without symptom provocation may indicate an intra-articular restriction and origin of symptoms. - Contraindications: High levels of irritability, surgical fixation/fusion, fracture suspicion o PAIVM testing is completed in the same position of PPIVM assessment if symptoms are provoked in straight plane ROM testing, likely neutral PPIVM/PAIVM testing is suitable to assess. If symptoms are provoked only in quadrant positions, PPIVM/PAIVM assessment can be biased into flexion or extension to identify a comparable sign and articular restriction. o Assessing quantity, quality of motion, end feel and looking for symptom provocation o Can become treatment if an intra-articular restriction is identified (PPIVM is positive for limitation AND PAIVM is positive for restricted end feel o A limited PAIVM glide that does NOT create symptoms may still be relevant to the patient s presentation. A non-painful hypomobility may be identified at a level neurophysiologically connected to a peripheral symptom (ie, a stiff by painless C5/6 with lateral epicondylalgia) o A non-painful hypomobility may also be found adjacent to a painful hypermobility (ie, C2/3 and C7/T1 restriction without pain but with symptom provocation without restriction to C5/6 assessment)