Cervical Spine Differential Diagnosis. Jason Zafereo, PT, OCS, FAAOMPT

Transcription

1 Cervical Spine Differential Diagnosis Jason Zafereo, PT, OCS, FAAOMPT Clinical i l Orthopedic Rehabilitation ti Education 1

2 Objectives Describe the relevant findings from the history and examination indicating the source of symptoms as: Contractile tissue Non-contractile tissue Nerve Spine Describe the relevant findings from the history and examination indicating a primary impairment of: Stiffness Weakness 2

3 3 CONTRACTILE TISSUE PATHOLOGY

4 Myofascial Pain Syndrome 4 55% of head and neck pain cases (Fricton et al 1985) 95% of chronic cases referred to pain management (Gerwin 1995) 41% of new patients (over a 5-month period) referred to otolaryngologist practice (Teachey 2004)

5 Myofascial Pain Syndrome 5 Elevation of contractile substances Acetylcholine Calcium Contraction knots Contracted sarcomeres Hypoxia and low ph Sensitization Travell and Simons 1999

6 Trigger Points (TrPs) Active Spontaneous pain at rest Pain on contraction or stretching t of muscle involved Mirror image motor unit activation in 61.5% patients with chronic neck pain (Audette et al 2004) Latent No spontaneous pain at rest May have pain on contraction or stretching No mirror image activation 6

7 Subjective Exam Findings Nature Aching, cramping, difficult to localize and referred to deep somatic tissues Aggravating Cold, stress, anxiety, sustained postures Easing Heat, massage Associated symptoms Affective-emotional pain component w/ heightened attention to painful stimuli Myofascial connection to anterior cingulate cortex/ periaquaductal gray (PAG) Headache 7

8 Subjective Exam Findings Location TrPs present in 93.9% of migraineurs, 29% of asymptomatic controls (Calandre et al 2004) Migraine location consistent with site of TrP referral from temples, suboccipitals (Giamberardino et al 2007) Location of TrPs in TTHA UT 75% Temporalis 74% SCM 60% 8

9 Subjective Exam Findings--Location 9 Travell and Simons 1999

10 Subjective Exam Findings--Location 10 Travell and Simons 1999

11 Subjective Exam Findings--Location 11 B involvement in fibromyalgia/ sensitization Multiple l active TrP sites in UTs (7.4/13), particularly mid-belly of muscle, compared to 0/13 active in normal controls Ge et al 2009

12 Diagnostic Criteria for TTHA Tension type headache has at least two of the following characteristics (IHS): bilateral location pressing/tightening (non-pulsating) quality mild or moderate intensity not aggravated by routine physical activity such as walking or climbing stairs Plus, both of the following: no nausea or vomiting (anorexia may occur) no more than one of photophobia h or phonophobia h 12

13 Objective Exam Findings for Myofascial Pain Test ROM/Flexibility Muscle Provocation Testing Palpation Response Restricted flexibility of involved muscle; Active and Passive ROM painful in opposite directions; CROM not significantly limited except with Levator and Splenius Cervicis TrPs Painful, possibly weak (no atrophy) 1) Focal tenderness with concordant sign reproduction (about 3kg of pressure) 2) Twitch response 3) Taut band 4) Often referred pain (non dermatomal) on continued (~5sec) pressure 13

14 Objective Exam Findings Palpation reliability Inter-rater reliability upper torso, k=0.74 (Gerwin et al 1997) Intra-rater rater reliability upper trap, ICC= (Barbero et al 2012) Inter-rater reliability upper trap Experienced, k=.63 Inexperienced, k=.22 (Myburgh et al 2011) 14

15 15 NON-CONTRACTILE TISSUE PATHOLOGY

16 Nerve Interface sites Disc (protrusion/prolapse) IVF (reduced AP diameter) 16

17 Subjective Exam Findings 17 Demographics <45 years (disc) >45 years (IVF) Aggravating g Nerve tension positions of neck or UE Coughing/sneezing/straining (disc) Closing positions neck (IVF) Intensity High severity and irritability Nature Sharp, shooting, linear, catching Easing (meds) Less responsive to NSAIDs, more to antiepileptic (Neurontin- Lyrica) or anti-depression (Amitriptyline) meds Associated neuro sx

18 18 Subjective Exam Findings--Location

19 Objective Exam Findings Test ROM Special Testing Neurological exam Palpation Response UE Active and Passive ROM limited and painful in same direction; Cervical spine rotation <60deg (IVF); Changes with repeated movements (disc?) Positive Cervical distraction; positive Spurling s; Positive ULTT Sensation, strength, and reflex may be altered at key sensory/motor points Tenderness over nerve trunks and involved segment 19

20 CPR for Cervical Radiculopathy 20 Key Tests (Wainner et al 2003) ULTT (K=.76, LR+=3.5, LR-=.58) Spurling s test (K=.60, LR+=3.50, LR-=.58) Distraction test (K=.88, LR+=4.40, 40 LR-=.62) Cervical rotation <60deg Cluster 3/4 positive, +LR = 6.1 (65%) 4/4 positive, +LR = 30.3 (90%)

21 Joint/Disc Local pain of joint/disc origin can be hard to distinguish Pathology specific exam usually not helpful ROM exam serves as primary means of identification Diagnosis of exclusion after ruling out nerve/muscle with pathology-specific exam 21

22 Subjective Exam Findings--Disc Age years old Onset Chronic, history of acute torticollis Nature Aching Associated symptoms May report pain with swallowing 22

23 Subjective Exam Findings Disc Location 23 C3/4 Mastoid, temple, TMJ, Parietal cranium C3/4 to C5/6 Occipital cranium, OA, Neck, Throat C3/4 to C6/7 Upper back, trapezius, Superior shoulder, UE C4/5 to C6/7 Anterior chest C6/7 Scapula

24 Subjective Exam Findings- Z Joint Location 24 Dwyer et al 1990; Fukui et al 1996

25 Diagnostic Criteria for Cervicogenic Headache (IHS***) Dull, not throbbing or lancinating*** Unilateral, in ram s horn distribution (may project to forehead, orbits) *** HA affected by cervical ROM/posture *** Migraine meds not helpful Largely female, mean age at onset History of trauma No significant nausea, phot/phon-ophobia, p p vertigo 25

26 Objective Exam Findings Test ROM Special Testing (Disc) Special Testing (HA) Palpation Response Active and Passive ROM painful in same direction***; Sagittal plane: Disc; Frontal plane: UVJ; Transverse plane: Joint/Disc; Look for centralization or directional preference Dural tension test: Increased pain with cervical flexion and scapular retraction Limited Cervical Flexion Rotation Test; Decreased performance on Craniocervical Flexion Test Tenderness over involved joints*** 26

27 Dural Testing 27 Anchoring of C5-7 roots to sulcus of transverse processes decreases effectiveness of neural testing Alternate mechanism for dural testing (Sizer et al 2001) Neck flexion with scapular retraction ti Tension on T1 root level

28 Diagnostic Accuracy of Special Testing 28 FRT Positive: ROM 32deg is significant ifi 91% sens, LR-=.09; 90% spec, LR+=9.32 (Ogince et al 2007) for dx CGH vs controls and migraine i w/ aura 63% C1/2 involvement in CGH (Hall et al 2010) CCFT (Jull et al 2007) Limited performance 26-30mmHg 100% sens, 94% spec when combined with ROM, palpation findings for dx CGH vs TTHA and migraine

29 29 PRIMARY STIFFNESS IMPAIRMENT

30 Objective Exam Findings Objective Exam Variable ROM Passive physiological movement Passive accessory movement Palpation/Observation Flexibility Response Limited ROM Capsular pattern; characteristic motion loss with firm end feel R1 occurs before P1 Tenderness, tightness, and presence of positional fault (TP/facet rotation/scapula) Limited in muscles prone to hypertonicity 30

31 Cervical ROM Diagram R L R L 31

32 32 Cervical Cardinal Plane Patterns

33 Upper Cervical Cardinal Plane Testing OA flexion/extension in rotated position C1/2 rotation in flexed position 33

34 Reliability of Motion Testing 34 Physiological Mobility K =.78 to 1.0 for C0-C3 Jull et al, Aust J Physiother, 1997 Mobility K = for C2-T2 (PA or 1-D Dtests) Pain ICC = for C2-T2 (PA or 1-D tests) Pool et al, J Manip Physiol Ther, 2004

35 Reliability of Motion Testing 35 Seated cervical sidebend test (with 3-D coupled motion) C2-3 to C6-7 Assess pain provocation, hypomobility, end feel K = Fair to moderate most painful side K = Fair to substantial least painful side (Manning et al 2012)

36 Common Motor Patterns 36 Ventral hyperactive musculature Pec minor Scalenes SCM Biceps Dorsal hyperactive musculature Middle and upper trapezius Levator scapulae

37 Flexibility Testing 37 Traditional, passive length assessment versus Active dominance assessment Upper trap dominance creates ipsilateral C2 SP movement with UE elevation Levator dominance creates contralateral C2 SP movement with UE elevation

38 38 PRIMARY WEAKNESS IMPAIRMENT

39 Subjective Exam Findings Subjective Exam Variable Mechanism Response Remote history of trauma; frequent episodes of acute attacks Aggravating factors Sustained weight-bearing i posture; sharp pain with sudden movements Easing factors Associated factors Manipulation; Non-weight bearing; external support (hands and collar) Popping, clicking, locking Fatigue and inability to hold head up 39

40 Objective Exam Findings Objective Exam Variable Active movements Passive physiological movement Passive accessory movement Strength testing Response Full general mobility with painful arc; aberrant motion; hinging, pivoting, fulcruming. Greater ROM in supine than in sitting/standing Full with decreased resistance to end range Increased neutral zone Weakness/poor coordination longus colli/capitus Palpation Atrophy of multifidus segmentally 40

41 Common Motor Patterns Dorsal hypoactive musculature Lower trapezius Serratus Supra- and dinfraspinatus i Deltoid Triceps Ventral hypotonic musculature Deep neck flexors 41

42 Strength Testing Trapezius Lower: Association between low trap weakness and side of neck pain (Petersen and Wyatt, 2011) Upper: Standing shrug with UEs overhead (Sahrmann 2002) 42

43 Strength Testing Serratus Anterior Position: Seated, shoulder deg. Resistance at upper arm downward and backward Normal: Holds scapular abduction/upward rotation Considerations: Pec minor and levator substitution 43

44 Details on Craniocervical Flexion Test (Jull et al 2004) Procedure Stabilizer to 20mmHg Chin nod without superficial activity 10sec x 10 Test results Normal = 26 mmhg Ideal = mmhg 44

45 Details on Neck Flexor Endurance Test 45 Procedure Max chin retraction ti Lift head 1in above plinth Test results (Harris et al 2005) Mean without neck pain = 38.95s Mean with neck pain = 24.1s Significant effect of gender (not age/activity) in normals (Domenech et al 2011) Men = 38.9s Women = 29.4s