Cervical Case Study M. Benson, A. Felts, S. Kibiloski, J. Mowen, A. - - PowerPoint PPT Presentation

Cervical Case Study

• M. Benson, A. Felts, S. Kibiloski,
• J. Mowen, A. Rijhwani

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

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

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

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

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

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

• Palpation

▫ Tenderness with trigger points in:

• L scalenes
• L levator scapula
• L upper and middle

trap

• L upper cervical

region

Objective Exam

• 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

Special Tests

ULTT

• Positive for median and radial nerve

Cervical Distraction

• Positive for symptom relief

Spurlings

• Positive with symptom reproduction

Outcome Measures

NDI

• 25/50

▫ MDC: 5 points ▫ 0 - 4 = no disability ▫ 5 - 14 = mild ▫ 15 - 24 = moderate ▫ 25 - 34 = severe ▫ above 34 = complete

SPADI

• Pain - 66%
• Disability - 55%
• Total disability for L shoulder -

59%

▫ MDC: 10% ▫ No disability= 0

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

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

ICF Model

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
• f 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

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

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?

A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy

Rubinstein et. al, European Spine Journal, 2007

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.

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

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

Results

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

Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy

Wainner et al. SPINE, 2003

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

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

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

Conclusion

What combination of tests is most accurate for diagnosing cervical radiculopathy in a 35-year

• ld woman with neck pain and radiating

symptoms? Cervical Distraction, Spurling’s, Cervical Rotation, ULTT 1

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?

Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review

Boyles et al. Journal of Manual and Manipulative Therapy, 2011

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.”

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

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

Conclusion

• Manual + Therapeutic Exercise = BEST
• Which intervention is responsible??
• Future high quality RCTs featuring control

groups needed.

Limitations

1. Only one article specifically prescribed the performed intervention. The

• ther 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.

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

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

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

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

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

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

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

Conclusion

• A multimodal treatment approach is superior

than either intervention alone ▫Combination of manual therapy and strengthening exercises

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

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

Class Goal & Intervention

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.

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.

Pain Relief

Education

Strengthening

Manual & Stretching

References

1. Boyles, R. et al. 2011. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. Journal of Manual and Manipulative Therapy, 135-142. 2. Ragonese, J. et al. 2009. A Randomized Control Trial Comparing Manual Therapy to Therapeutic Exercises, to a Combination of Therapies, for the Treatment of Cervical Radiculopathy. Orthopedic Practice, 71-76. 3. Rubinstein, S, M. et al. 2007. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical

• radiculopathy. European Spine Journal, 307-319.

4. Wainer, R. S. et al.,2003. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. SPINE, 52-62.

Questions?