Thomas M. Dodge, PhD, ATC, CSCS Springfield College Springfield, MA - - PowerPoint PPT Presentation

Thomas M. Dodge, PhD, ATC, CSCS Springfield College Springfield, MA

Outline

 Relevance  Functional Anatomy  Treatment options

 Electrotherapies  Manual Therapies  Therapeutic Exercise

 Conclusions

Relevance

 Cervical pain affects approximately 15%

• f the population (Cote et al., 2004)

 Debilitating nature of cervical pain  Cervical pain has a multitude of causes  Difficult to treat

 Upper segments

 45° superior to the

transverse plane

 Lower segments

 More vertical position

Musculature (Ylinen, 2007)

 Isometric function

 Posture  Stabilization

 Dynamic function

 Position head for better sensory input

○ Proprioception ○ Sight, hearing, olfaction, etc.

 Relationship to shoulders

 Elevation  Inspiration

Common Injuries

 Myofascial Trigger Points  Cervical Strains  Joint Restrictions/Facet Joint Pathology  Cervical Instabilities  Disc Pathologies  Radicular Pain  Cervicogenic Headaches

Postural Issues

Treatments

Electrotherapy

Efficacy of IFC

 Fuentes et al. (2010)

 IFC provides modest relief for

musculoskeletal pain as part of a multimodal treatment approach

○ Acute or Chronic ○ 3 Month Follow Up

 No specific neck studies included in meta-

analysis

Electrotherapy

 TENS coupled with Ischemic

compression leads to greater initial reduction in pain (Hou et al., 2002)

 TENS intervention lead to improvements

in strength, pain, and disability status at both 6 weeks and 6 month follow-up (Chiu et al., 2005)

Electrotherapy Bottom Line

 Cochrane Review (Kroeling et al., 2009)

 Low level of evidence supporting IFC as a

treatment for c-spine pain

 Bottom Line:

 Its probably worth trying, but not in isolation

Traction/Mobilization Techniques

Traction/Mobilization

 Contraindications  Vertebral Fracture  Vertebral Dislocation  Hypermobility  Disease/Infection  Vertebral Artery

Dysfunction

 Severe Disc

Herniation

 Arthritis?

Traction

Cer ervical vical Traction action Clinical inical Prediction ediction Rul ule e (Rane ney y et al et al, , 2009) 9)

 Peripheralization with mobility testing

 C4-C7

 (+) Shoulder Abduction Test  Age ≥ 55  (+) Upper Limb Tension Test  (+) Cervical Distraction Test

Mobility Testing

Shoulder Abduction Test

Cervical Distraction Test

Upper Limb Tension Test

Cer ervical vical Traction action Clinical inical Prediction ediction Rul ule e (Rane ney y et al et al, , 2009) 9)

 Peripheralization with mobility testing

 C4-C7

 (+) Shoulder Abduction Test  Age ≥ 55  (+) Upper Limb Tension Test  (+) Cervical Distraction Test  79.2% Success rate with 3 factors  94.8% Success rate with 4 factors

Manual Cervical Traction

Traction/Trigger Point Pressure

Cervical Traction

 Patients with radicular symptoms of less

than 12 weeks reported a reduction in pain and perceived disability with mechanical traction (Moeti & Marchetti, 2001).

 Centralization can be accomplished

through a combination of traction and retraction exercises (Werneke & Hart, 2003).

Cervical Traction

 More recent research (Chiu et al. 2011,

Young et al., 2009) suggests that traction is not a necessary addition to the treatment protocol when treating chronic and/or radicular pain with manual therapy and therapeutic exercise.

 Bottom line: Utilize the CPR for optimal

results

Thoracic Thrust Mobilization

Thoracic Thrust Mobilization CPR (Cleland et al, 2007)

 Symptoms < 30 days  No symptoms distal to the shoulder  Looking up does not aggravate

symptoms

 FABQPA score <12  Diminished upper spine kyphosis  Cervical extension ROM < 30°  3 or more = 86% success rate

Thoracic Mobilization Evaluation

Thoracic Mobilization Evaluation

Thoracic Mobilization

Thoracic Mobilization

Thoracic Spine Thrust Mobilization

 Thoracic spine thrust mobilization

results in significantly greater short-term reductions in pain and disability than does thoracic nonthrust mobilization in people with neck pain (Cleland et al., 2007)

Thoracic Thrust Mobilization CPR 2010 update (Cleland et al.)

 Validity of original CPR not supported  Long and short term improvements in

pain and neck disability

 TTM supported as a viable treatment for all

patients with mechanical neck pain

Therapeutic Exercise

Chin Tuck Maneuver

Chin Tuck With Bladder

Chin Tuck Progression



Start on the table in anatomical position

1.

Progressive Tension

○

22, 24, 26, 28, 30 2.

Elbow flexion and extension

3.

GH Internal/external rotation

4.

GH abduction and flexion/extension

5.

Scapular protraction, depression, elevation

6.

Diagonal patterns (PNF)

Chin Tuck Progression

Moving Off The Table

Progression Off The Table

Therapeutic Exercise

 Resistance exercise, when training

volume is appropriate, can significantly reduce neck pain and disability (Ylinen et al. 2003).

 Dynamic and isometric training of the

neck musculature significantly increases pressure pain threshold (PPT) in neck muscles (Ylinen et al. 2005).

Loading

 Patients must possess sufficient

strength to cope with tasks that require higher loading levels during recreational and work activities. (Ylinen, 2007)

 Long –term moderate to high intensity

training of the neck musculature is appropriate for reduction and prevention

• f chronic neck pain (Ylinen, 2007)

Conclusions

 Electrotherapy is viable treatment option  Mobilization and traction techniques are

useful when indicated

 Posture and the Kinetic Chain

 Thoracic mobility

 Rehabilitation

 Deep Neck Flexors  Progressive Loading  Treatment of cervical spine should always

follow a multimodal approach (Miller et al., 2010)

References



Chiu TT; Ng JK; Walther-Zhang B et al. A randomized controlled trial on the efficacy of intermittent cervical traction for patients with chronic neck pain. Clin Rehabil. 2011;25:814-22.



Chiu TW, Hui-Chan WY, Cheing G. A randomized clinical trial of TENS and exercise for patients with chronic neck pain. Clin Rehabil. 2005;9:850-860.



Cleland JA, Mintken PE, Carpenter K, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: Multi-center randomized clinical trial. Phys Ther. 2010;90:1239-1250.



Cleland JA, Glynn P, Whitman JM, et al. Short-term effects of thrust versus non-thrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: A randomized clinical trial. Phys Ther. 2007;87:431-440.



Cleland JA, Childs JD, Fritz JM et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise and patient education. Phys Ther. 2007;87:9-23.



Cote P, Cassidy JD, Carrol LJ, et al. The annual incidence and course of neck pain in the general population: a population- based cohort study. Pain. 2004;112:267-273.



Fuentes JP, Olivio SA, Magee DJ et al. Effectiveness of Interferential Current Therapy in the Management of Musculoskeletal Pain: A Systematic Review and Meta-Analysis. Phys Ther. 2010;90:219-1238.



Hou CR, Tsai LC, Cheng KF, et al. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. 2002;83:1406–1414.



Kroeling P, Gross A, Goldsmith CH, et al. Electrotherapy for neck pain. Cochrane Database of Systematic Reviews 2009, Issue 4.



Miller J, Gross A, D’sylva J, et al. Manual therapy and exercise for neck pain: A systematic review. Manual Therapy. 2010;15:334-354.



Moeti P, Marchetti G. Clinical outcome from mechanical intermittent cervical traction for the treatment of cervical radiculopathy: A case series. JOSPT. 2001;31(4):207-213.



Raney NH, Petersen EJ, Smith TA, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009;18:382-391.



Werneke M, Hart DL. Discriminant validity and relative precision for classifying patients with nonspecific neck and back pain by anatomic pain patterns. Spine. 2003;28:161–166.



Ylinen J, Takala EP, Kautiainen H. et al. Effect of long-term neck muscle training on pressure pain threshold: A randomized controlled trial. Eur J Pain. 2005;9:673-681.



Ylinen J, Takala EP, Nykanen M et al. Active neck muscle training in the treatment of chronic neck pain in women: A randomized controlled trial. JAMA. 2003;289:2509-2516.



Ylinen J. Physical exercises and functional rehabilitation for the management of chronic neck pain. Eura Medicophys. 2007;43:119-32.



Young IA; Michener LA; Cleland JA et al., Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized clinical trial. Phys Ther. 2009;89:632-42.

 TDodge@spfldcol.edu