Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_138_библиотеки_им_акад_М_И_Перельмана
.pdf
in a motion that combines an upward distraction and slight
https://t.me/med1917
counterforce with their pectoral region.
oracic manipulation (seated)
Because the thoracic spine can refer pain to the cervical
spine and vice versa, thoracic manipulations are an intervention
option to achieve decreased pain and increased ROM for the
cervical and thoracic regions. is intervention can be especially
helpful if a patient has apprehension of cervical manipulation
but more comfort with the same technique applied to the
thoracic spine or when patients have high irritability. Finally,
thoracic manipulation can be useful when manipulative
techniques to the cervical spine might be contraindicated.
e patient is seated and moved backward until they
are sitting near the back edge of the plinth (Figure 21). e
therapist is standing in a stride stance behind the patient. e
patient is asked to give themself a hug, essentially horizontally
adducting their arms to introduce tension to the thoracic spine.
It is important that the elbows are stacked and that the forearms
are not crossed. e therapist then wraps their arms around
the patient interlocking their hands over both, or at least the
bottom, elbow. e therapist shifts their weight so they are
balanced on each leg and uses the patient’s elbows to flex then
distract the thoracic spine. e movement of the elbows is often
referred to as a “J-hook” and describes the force that occurs
in a more curvilinear fashion rather than a straight line to the
therapist’s body. For the manipulation, the therapist applies a
HVLA force in a motion that combines an upward distraction
and slight counterforce with their pectoral region.
Modied version: For therapists who have discomfort using
their pectoral region, a towel roll can be placed perpendicular
to the patient’s spine at the targeted level and then in the upper
pectoral region of the therapist.
Figure 21.
A
B
Seated oracic Manipulation
oracic manipulation (supine)
As previously mentioned, thoracic manipulation is a
beneficial intervention for those who have neck pain and
may be apprehensive of, or have precautions against, cervical
manipulation. e advantage of this intervention versus the
seated technique is that some patients are more comfortable and
able to relax in a supine position, and the supine position allows
the therapist to work with gravity versus distracting the patient
against gravity in a seated position. Both interventions have
their advantages, and it is ultimately up to the patient’s comfort
and therapist’s preference as to which technique is selected.
For this technique, the patient is supine and asked to move
close to the side that the therapist is standing (Figure 22). e
patient crosses arms with the contralateral arm on top (elbows
stacked without forearms cross). Having the patient cross arms
over a towel or small pillow can help the elbows be aligned
and decrease stress on hypermobile glenohumeral joints. e
therapist rolls the patient towards them to locate the target
segment, then uses a pistol grip with their fulcrum hand on
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
39
A, Lateral view. B, Anterior view.
Figure 22.
oracic Manipulation Supine
the target segment. If the pistol grip is uncomfortable for the
https://t.me/med1917
therapist, an open hand with slight opposition of the thenar
and hypothenar eminences can be used to create a fulcrum.
Once the fulcrum hand is positioned, the patient is rolled back
over the fulcrum hand and the therapist uses their other hand
as a barrier between the patient’s elbows and their body. e
elbows are used to flex the thoracic spine until the therapist feels
the line of force directed just superior to their fulcrum hand
and then applies a HVLA force in a posterior direction down
towards the plinth.
oracic manipulation (prone)
e prone thoracic manipulation is sometimes thought of
as an extension-oriented intervention; meaning if a patient has
limitations and hypomobility into thoracic extension, then this
would be the intervention of choice. at being said, this can
still be a beneficial intervention as a general manual therapy
intervention for thoracic and/or neck pain. e advantage of
this intervention is that the patient is in the same position as
when assessing thoracic central and unilateral PA segmental
mobility. So, after assessing cervical and thoracic active and
passive ROM, and segmental mobility, this is a quick and
seamless intervention to transition into.
For this technique, the patient is prone with the therapist
standing to the side of the plinth (Figure 23). e therapist
identifies the spinous process of the target vertebra and contacts
the ipsilateral facet with the pisiform of the cranial hand while
the pisiform of the caudal hand contacts the contralateral facet.
To acquire a necessary skin-lock, the therapist begins with their
hands rotated ~90° (fingers pointing laterally), then rotating
them to end with their fingers pointing cranially and caudally.
Figure 23.
oracic Manipulation Prone
e manipulative force is then directed straight down to the
direction of the floor as the therapist lowers their body.
It might seem daunting to review the relatively large list of
manual therapy techniques and think about considering which
is optimal for a given patient. is sentiment perhaps grows
further when one realizes the list here is just a fraction of the
multitude of techniques and variations on techniques that exist.
In these instances, the authors would like to remind the readers
that in very few instances is one technique absolutely superior
to another. Because the incidence of harm and side effects is
low, clinicians can feel comfortable experimenting with various
techniques in various situations to find those techniques they
are most comfortable or achieve superior results with. is
clinical experimentation in practice works so long as there
remains some biological plausibility for why a given technique
should be employed.
Intervention Strategies: Neck Pain with
Movement Coordination Impairments
Although this category primarily focuses on patients
with WAD presentation, those individuals with atraumatic
presentation of movement coordination impairments can also
benefit from the intervention strategies listed here.
e first consideration for intervention planning for
patients with movement coordination impairments or WAD
is establishing the likely trajectory or prognosis for the
clinical course. Patients with WAD likely take 1 of 3 different
pathways: mild problems with rapid recovery (approximately
45% of individuals depending on outcome), moderate
problems with some but incomplete recovery (approximately
40% of individuals), and severe problems with no recovery
(approximately 15% of individuals).
8
Walton et al
31,106
established a framework of predictors for prolonged symptoms
using meta-analytic techniques on a collection of systematic
reviews. It was determined in the study that high pain intensity
and high self-reported disability offer the greatest prognostic
value for patients with WAD. Table 4 outlines predictors for
8
prolonged symptoms after injury.
A clinical prediction tool, referred to as WhipPredict,
that stratifies risk for poor recovery has also been developed.
107
In this model, moderate/severe disability at 12 months was
predicted by age ≥35 years, NDI scores ≥40%, and hyperarousal
symptoms ≥6 on the hyperarousal subscale of the Posttraumatic
Stress Diagnostic Scale. Full recovery was predicted in younger
individuals (<35 years) with NDI scores ≤32%. Another
important prognostic consideration for patients with WAD is
that the majority of recovery takes place in the first 3 months
30,31
following the injury event.
For patients with a positive prognosis in the acute phase,
meaning a rapid recovery, a light touch approach is advocated by
guidelines. ese patients should be weaned off of any cervical
collars, and ROM and postural awareness activities should be
40
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
undertaken as a home program. Additionally, these patients
https://t.me/med1917
should receive advice to remain active and carry on as usual
while the provider monitors the patient to ensure acceptable
progress is being made.
e next subgroup to consider are the patients with
poorer prognoses in the subacute phase. e approach for these
patients differs in that they may benefit from manual therapy
and regionally based exercises to the cervical and thoracic
spine to manage pain, restore motion, and optimize recovery
of movement coordination deficits. is could include cervical
mobilization or manipulation, thoracic manipulation, isometric
low-load strengthening, and neuromuscular exercises that
includes movement coordination and stabilization elements.
However, delivering best-evidence care for this subgroup has
not been shown to improve or significantly alter their trajectory
toward a poor prognosis at this time.
8,32,86,106,108
Lastly, for patients with prolonged symptoms, a progressive
strategy of low-load cervicoscapulothoracic strengthening,
endurance, and flexibility exercises should be combined
with functional training.
therapy principles can be helpful for this group of patients.
109
e use of cognitive behavioral
110
Additionally, vestibular rehabilitation, eye-head-neck
coordination, and neuromuscular coordination elements can be
employed via a multi-pronged strategy to encourage patients
to continue working to optimize their function and minimize
symptoms.
111–113
Likewise, this group may only realize limited
gains as the prognostic trajectory remains stubborn despite bestevidence interventions.
Deep neck flexors training
While this intervention is currently categorized under neck
pain with movement coordination impairments, it is important
to note that this is an appropriate intervention for any patient
that has been found to have a limitation in their CCF test or
deep neck flexor endurance test. e patient populations most
suitable for these assessments and interventions are those with
chronic neck pain, cervicogenic headache, WAD, and general
movement coordination dysfunction.
For this training, the patient is positioned supine without
a pillow under their head, if they are able to comfortably
maintain this position. e patient is first taught to palpate the
SCM muscle and differentiate when it is engaged or relaxed.
e patient is then instructed to perform CCF with cues such
as “nod your head” or “tuck your chin into a double chin.” e
goal is to be able to perform 10 repetitions with a 10 second
114
hold.
is position can be regressed by having the patient
on a pillow or performing the exercises on an inclined chair.
Progression would include a 1-inch head lift. Note that a
recent systematic review found that while deep neck flexors
training can improve movement coordination for patients with
cervicogenic headache, a multimodal and regional approach is
probably required to improve strength and endurance of these
muscles.
115
Once a patient has progressed and achieves satisfactory
performance in the supine position, more functional activities
can be pursued and incorporated into training. Various postures
including sitting, standing, kneeling, or quadruped can provide
different challenges to deep neck stabilizers. Combining
functional body movements, through an obstacle course for
example, or use of the upper extremities in a functional task,
as another example, while maintaining specific head positions,
are other ways of progressing strength, endurance, and overall
function of the deep neck flexors.
Beyond deep neck flexor training and use of the
aforementioned strategies, it can be helpful to review a patient’s
pain experience utilizing the previously described radar plot
graphs. Because the categories in these plots generally align with
intervention areas, it can help pointing clinicians to directions of
treatments or interprofessional referral that may be beneficial to
patients. While outside the scope of this monograph, techniques
to reduce the impact of nociplastic changes are currently the
recipients of much translational research and can be trialed in
those patients where appropriate. Likewise, paying attention to
socioeconomic factors might enable a greater benefit for those
interventions already being employed.
Intervention Strategy: Neck Pain with Headaches
It might not be surprising to realize that for patients with
cervicogenic headache, the majority of deficits occur in the upper
100,116
cervical spine or craniovertebral junction.
As such, manual
therapy techniques focused on regaining normal mobility to
117
the upper cervical spine are advised.
Additionally, exercise for
cervical and scapulothoracic region that includes both strength
and endurance activities integrated with neuromuscular training
is helpful for this group of patients.
114
A classic randomized clinical trial by Jull et al
effectively
outlined an optimal treatment strategy for patients with
cervicogenic headache. In this trial, moderate, clinically relevant
effect sizes were realized with both manual therapy or exercise.
But, the combination of manual therapy and exercise provided
114
increased benefit over each therapy alone.
e treatment was
provided over 4 weeks and outcomes were based on reductions
in headache frequency. Below are some interventions referenced
in various studies that can assist with patients experiencing neck
pain with headaches.
8,72,100,114
Atlanto-occipital (OA) joint flexion mobilization
Patients who report headache symptoms in a seated
activity, such as driving or working on a computer, and present
with a forward head posture in sitting, would lead a therapist to
assess their OA joint mobility. While it is important to assess all
directions, individuals in a forward head posture tend to rest in
OA extension and subsequently have limited OA flexion. If OA
flexion is found to be limited, then an OA flexion mobilization
could be indicated.
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
41
For this mobilization, the patient is supine with the
https://t.me/med1917
therapist standing at the head of the table. One hand is cradling
the occiput while the other hand contacts the patient’s forehead.
e therapist uses both hands to roll the cranium into flexion.
e head should remain on the plinth ensuring the rest of the
cervical spine stays in neutral. To bias the mobilization to one
side, ipsilaterally rotate the patient’s head 30°. is should
position the desired OA joint in the therapist’s hand that is
resting on the plinth. en, the mobilization is a cranial flexion
with slight contralateral side flexion. is motion is created
by still mobilizing straight towards the plinth. As previously
mentioned for other manual therapy techniques, following the
intervention, the therapist should reassess the patient’s objective
finding(s) that reproduced their symptoms for qualitative
and quantitative changes. is should also be done for the
subsequent techniques described below.
Atlanto-occipital (OA) joint flexion contract-relax
If OA joint mobility is assessed as hypomobile and
the limitation seems to be muscular, then a contract-relax
intervention is indicated. Muscular-based impairments
tend to feel more elastic at end-range compared to the firm
capsular end-feel of joint motion limitations. Additionally,
the therapist might transition to a contract-relax technique if
the initial intervention selection is OA flexion mobilization,
and the patient is not tolerating the intervention. To perform
the contract-relax technique, the therapist performs the same
mobilization described above (in neutral or biased to 1 side) and
maintains the end-range position. e patient is then instructed
to “look up” with their eyes for 10 seconds, then to relax. e
action of looking-up should produce a reflex activation of
the suboccipital musculature, perceived and resisted by the
therapist. As the patient relaxes, the therapist gently moves
the patient into an increased flexion ROM if possible. is is
generally performed for 3 repetitions.
Inherent in this technique is the assumed relationship
between eye muscle activation or eye movements and cervical
muscle activation. Relationships between the eyes and head
position are complex and associated with several reflexes,
including the vestibular ocular reflex and the ocular-muscular
118
reflex.
ese reflexes describe how positional changes of
the head or eyes result in movement of neck muscles as part
of an effort to stabilize the head and gaze. ere has been
recent work that describes the interaction between specific eye
movements and cervical muscles, although the mechanisms
119–122
are not fully elucidated.
in this interaction. Bexander et al
Tonic coupling may play a role
120
demonstrated that the
position of the eye in the orbit can influence muscle activity in
both superficial and deep cervical muscles that is directionally
dependent. While the contract-relax technique has existed in
practice for some time, it is interesting that recent research is
beginning to help explain some of the mechanisms for how this
procedure imparts its effect.
Atlanto-occipital (OA) joint distraction manipulation
Prior to this intervention, the therapist should have a
clear understanding of the patient’s cardiovascular risk factors,
history of trauma, and symptom presentation. Performed on
the appropriate patient, this could be a particularly helpful
intervention for patients with upper cervical mobility deficits
and cervicogenic headache.
For this intervention, the patient is supine and the
therapist stands at the head of the table towards the affected
side of the patient. e contralateral hand supports the patient
in a chin hold with the therapist’s forearm lying posterior to
the patient’s ear. e mobilizing hand contacts the occiput just
superior to the target OA joint with the first MCP joint. e
patient’s head is positioned in slight contralateral rotation and
ipsilateral side flexion. At this point, the therapist moves to the
side of the table so that the forearm of the mobilizing hand
changes direction and now points superiorly, while the wrist is
maintained in neutral. e HVLA force occurs in a cephalad
direction providing a distraction force (Figure 24).
Atlanto-axial (AA) joint rotation contract-relax
Along with OA mobility assessments, the upper cervical
assessment includes the craniocervical flexion-rotation test to
assess for limitations in AA joint rotations. If a limitation of AA
rotation is noted, the AA contract-relax intervention would be
an ideal intervention.
For this, the patient lies supine while the clinician passively
flexes the cervical spine maximally to end-range (Figure 25).
e clinician then passively rotates the head left and right
ensuring the cervical spine does not drift into side flexion or
back into extension. While maintaining rotation the patient
is instructed to look into contralateral rotation with their eyes
holding for 10 seconds, then have the patient relax. As the
Figure 24.
Atlanto-occipital Joint Distraction
Manipulation
42
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Figure 25.
https://t.me/med1917
Atlanto-axial Joint Contract-Relax Tech-
nique to Improve Right Cervical Rotation
patient relaxes, the therapist gently moves the patient into an
increased rotation ROM if possible. is is generally performed
for 3 repetitions. See the above discussion for the mechanism
underlying this technique.
Intervention Strategy: Neck Pain with Radiating Pain
According to clinical guidelines, patients with radicular
pain in the acute phase may benefit from low level laser therapy
or possibly a short-term use of a cervical collar. Manual therapy
is still indicated although this has reduced evidentiary support.
Exercises to promote mobility and stability are indicated.
For patients with chronic radicular symptoms, intermittent
cervical traction can provide an additional benefit to the use
of manual therapy and exercise. Neurodynamic mobilization
activities can be used effectively in this patient population as well.
Recent evidence suggests that overall, cervical radiculopathy has
a positive clinical course, and that this can be enhanced by the
prescription of neck-specific exercises, general exercises, and
cognitive behavioral strategies.
72
As with other categories, clinicians may find that patients
present with mobility restrictions alongside their nerve rootrelated symptoms. For this reason, joint mobilization and
flexibility interventions are indicated for this group. For patients
with chronic symptoms for whom traction may be beneficial,
the authors have found that home cervical traction units can be
effectively deployed as part of a home program.
Nerve glides (or sliders) are a beneficial intervention
strategy for patients with neck pain with radiating pain. Prior
to reaching an intervention decision the therapist should
have performed upper limb neurodynamic assessments. e
movements of the upper extremity described in the ‘tension’
tests are the movements that are thought to increase tension to
the nervous system including contralateral cervical side flexion.
To perform a slider, the therapist would decrease tension in
one joint while increasing tension at another so that the nerve
is not elongated by tension but instead moved through the
neural sheath. For example, with the patient in the tension
test position for the median nerve a slider could be produced
with simultaneous wrist extension and ipsilateral cervical side
flexion followed by wrist flexion and contralateral cervical side
flexion. Likewise, a median nerve slider could be produced with
simultaneous wrist extension and elbow flexion followed by
wrist flexion and elbow extension. e decision for one slider
over the other depends on the patient’s ability to comfortably
move their cervical spine into side flexion as well as their ability
to independently reproduce the movement as part of their
home exercise program.
Sliders are the ideal intervention for patients with moderate
to highly irritable radicular symptoms because the goal is for
the intervention to decrease their symptoms or not reproduce
the symptoms at all. It is theorized that the movement of
the nerve in the sheath reduces inflammatory mediators and
123
reduces irritability.
is will require educating the patient
that the goal is to not have symptom reproduction during the
intervention and home exercise.
Other Cervical Conditions
In addition to utilizing a classification-based system to
manage patients with neck pain, it can be useful to also discuss
and understand specific pathoanatomical conditions or drivers
of observed dysfunction. In many cases, patients will hear
pathoanatomical language from their medical care providers,
and so being able to correlate how a degenerative cervical disc
links with either neck pain with mobility deficits and radicular
symptoms are just one example of clinical conversations that
occur regularly. Even if a clinician relies heavily on classification
per the CPGs, not recognizing or considering the anatomical
changes that occur in the body can yield a limited view of how
patients are presenting in the clinic and can inform prognosis.
Cervical disc pathology
Cervical discs undergo significant stress in normal life as
they are subject to the large ROM available in the cervical spine.
Earlier, we described the discs as having annular regions that are
not complete circles, but rather anterior and posterior portions.
Some authors have suggested that discs begin life with full
circumferential annulus fibrosus, but that small fractures and
tears within the cervical disc, mostly occurring laterally, result
124
in separation of the 2 halves by the second decade of life.
As
individuals continue to age, the nuclear material of the discs can
protrude and cause compression on cervical nerve roots and/or
the spinal cord. ese changes occur commonly in the 4th and
5th decades of life. ese patients with deteriorating cervical
discs that have extruding nuclear material may likely fall within
the cervical radiculopathy subgroup.
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
43
e lifetime prevalence of painful cervical disc degeneration
https://t.me/med1917
is 45%, thus many people experience cervical disc degeneration
125
that is not painful.
However, some disc degeneration will
be symptomatic, and result in pain from the disc itself or
by resulting inflammation on nerve roots or surrounding
structures. Clinicians should consider the age-related changes
as they assess mobility and neck pain in patients. e group
of patients with non-specific age-related changes that includes
some degenerative changes in the cervical spine will likely fall
into the neck pain with mobility deficits subgroup.
Cervical myelopathy
Cervical myelopathy can be caused from degenerative
or non-degenerative processes. Non-degenerative causes of
cervical myelopathy can be syringomyelia or tumor. But, the
vast majority of cervical myelopathy is the result of age-related
degenerative changes, with some evidence pointing to the fact
that it is present in almost 90% of individuals in their 7th
124
decade of life.
over the age of 55, in males, and those of Asian descent.
Cervical myelopathy occurs more frequently
1,9
It
is theorized that the natural age-related changes in the cervical
spine including loss of disc height, in-folding and thickening of
ligaments, and reduction in vertebral canal space all contribute
to the presence of cervical myelopathy. However, diagnosis of
this condition is somewhat elusive, as classically individuals
present with variable signs and symptoms.
1
Cook et al
explored special tests and findings related to
cervical myelopathy via a systematic review and found that
most tests for this condition have moderate to high specificity,
but low sensitivity. ey reported that the most sensitive sign
1,126
was the inverted supinator sign. Cook et al
also developed,
from a low-quality trial, a cluster of 5 variables aimed to help
in making a diagnosis: age over 45 years, a positive Babinski
sign, a positive inverted supinator sign, a positive Hoffmann
sign, and gait dysfunction that includes spastic, wide-based gait,
or ataxia. is cluster, if no positive findings were observed,
resulted in a sensitivity of 0.94 and a negative likelihood ratio of
0.18, producing sufficient screening power to rule out cervical
radiculopathy. Conversely, if 3 or more variables were present,
the positive likelihood ratio for this cluster was 30.9, indicating
a high probability for the condition to be present. But it should
be noted that the 95% confidence intervals were wide in this
trial, speaking of the lack of precision of the rule. Clinicians
should consider these data regarding cervical myelopathy
diagnostic validity as they assess and manage older adults.
Physical therapy treatment including manual therapy and
ROM and strengthening exercises, among other interventions,
can be helpful in the management of cervical myelopathy. For
some patients, the progression of neurological symptoms is
not rapid, and these patients have the opportunity to perhaps
127
improve function with treatment.
Because altered gait
and balance is not an uncommon finding for patients with
cervical myelopathy, mitigation of fall risk should be included
in treatments. Even for patients who require decompression
surgically, physical therapy can be indicated to assist with
recovery of muscle weakness, improvement in balance, and
128
maximizing function post-operatively.
Summary
Neck pain is often non-specific, and few patients will
present to physical therapy clinics with overwhelmingly clear
identifiable tissue pathologies. at said, many patients with
neck pain can be easily categorized into groups based on
historical and clinical examination findings. erefore, careful
regional assessments of impairments will yield information
helpful in making treatment decisions for patients with neck
pain, and strong evidence exists to support the use of physical
therapy for patients with neck pain.
CASE SCENARIOS
Case Scenario 1
Cynthia is a 24-year-old female who experienced a motor
vehicle collision 2-weeks prior. She experienced neck pain
immediately and was transported to the hospital via ambulance,
where she says her neck was cleared of serious injury via a
standard series of radiographs. She presents to physical therapy
with complaints of neck pain, headache, and a reduced ability
to move her head.
1.
What additional condition should the physical therapist
screen for that could be considered a serious injury?
a. Odontoid fracture.
b. Facet joint dislocation.
c. Transverse ligament injury.
d. Occipital fracture.
e correct answer is c. Transverse ligament injury.
A standard cervical spine radiograph series is unlikely to
demonstrate ligamentous integrity or disruption, and physical
therapists should screen for ligamentous laxity after trauma.
We have no reason to doubt her reports that the radiographs
previously taken were negative making all other options
incorrect. e standard series should include anterior-posterior,
lateral, and odontoid views.
2. Based on the available information, which classification of
neck pain does Cynthia primarily fit into?
a. Mobility deficits.
b. Cervicogenic headache.
c. Movement coordination impairments.
d. Radiating pain.
e correct answer is c. Movement coordination
impairments. Pain, headache, and limited motion following a
motor vehicle collision is consistent with whiplash associated
disorders, or neck pain with movement coordination
44
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
impairments. While the patient does have headache and limited
https://t.me/med1917
mobility, these would not be the primary classification because
of the trauma experienced. ere is no mention of any arm
symptoms, therefore radiating pain would not be a correct
classification.
3.
Upon examination, the physical therapist notes several
factors that could result in Cynthia experiencing persistent,
severe pain. Which finding is consistent with this prognostic
assessment?
a. Weak deep neck flexors.
b. Pressure pain threshold is reduced.
c. Low fear avoidance.
d. No change in symptoms with Sharp-Purser test.
e correct answer is b. Pressure pain threshold is
reduced. is result indicates that Cynthia’s nervous system
has become sensitized to pain and is an indicator of possible
persistent pain. Deep neck flexor weakness is not associated
with a patient prognosis for experiencing persistent pain; this is
a common finding in patient with and without persistent pain.
A higher fear-avoidance would indicate someone who avoids
potential pain provoking activities/situations and is a risk factor
for developing persistent pain. No change is symptoms with
Sharp-Purser test is a normal finding.
4.
Which intervention is best supported by evidence for
Cynthia’s presentation?
Advice to remain active and continue daily activities per
a.
usual.
b. Grade IV lateral glide mobilizations.
c. Deep neck flexor coordination exercises.
d. High intensity resistance training.
e correct answer is c. Deep neck flexor coordination
exercises. General exercise and low load coordination activities
and strengthening are indicated in the acute phase for patients
with neck pain with movement coordination impairments that
have concerning prognoses. In the acute phase of the injury,
relative rest is indicated. Advice to maintain the previous activity
level would not be the appropriate recommendation while being
active in a reduced capacity would be ideal. Likewise, neither
high intensity training nor grade IV lateral glide mobilizations
are indicated for this phase of injury.
Case Scenario 2
Cash is a 32-year-old banjo player in a bluegrass band and
presents to physical therapy with complaints of neck and left
arm pain. He is right hand dominant and has a past medical
history that is insignificant, and he takes no medications. He
reports his pain as burning and it extends from the left lateral
neck to the left elbow. He also experiences burning pain along
the medial scapular border. Overall pain intensity is 6/10 on
a numeric pain rating scale. He reports pain increases while
playing the banjo, and he has been unable to perform over the
past several weeks.
1. Which cluster of tests would best assist in ruling in a diagnosis
of cervical radiculopathy?
a. Spurling test, limited extension ROM, neck flexor
endurance test.
b. Distraction test, upper limb tension test A, limited neck
rotation ROM.
c. Valsalva test, neck rotation ROM, upper limb tension
test C.
d. Spurling’s test, limited neck flexion, distraction test.
e correct answer is b. Distraction test, upper limb
tension test A, limited neck rotation ROM. is best fits the
tests in the item cluster for cervical radiculopathy, or neck pain
with radiating pain.
2. Cash reports the pain increases when the left arm is placed
in combined shoulder abduction and external rotation,
elbow extension, and forearm supination during the clinical
examination. What motion would best reduce the pain?
a. Left cervical lateral flexion.
b. Right cervical lateral flexion.
c. Shoulder flexion.
d. Wrist extension.
e correct answer is a. Left cervical lateral flexion. is
question describes a positive upper limb tension test A for the
median nerve. Tension can be released via ipsilateral cervical
flexion. Right cervical lateral flexion would increase the tension
and thus the patient’s symptoms. Both shoulder flexion and
wrist extension are sensitizing positions and thus would increase
the patient’s symptoms.
3.
What best describes the concept to use a gliding technique
for promoting neurodynamic mobility?
Glides can increase collagen formation resulting in
a.
increased neural length.
b. Glides result in elongation of the neural sheath.
c. Glides promote significant nerve fiber mobility without
increasing tension.
Glides promote decreased neutrophil aggregation result-
d.
ing in decreased pain.
e correct answer is c. Glides promote significant nerve
fiber mobility without increasing tension. It is theorized
that the increase in dynamic movement without increases in
tissue tension help reduce irritability and decrease inflammatory
mediators. Gliding maneuvers does not increase the length,
elongation, or tension of the neural structures as a tensioning
technique would.
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
45
4. What is the most appropriate home program for cash?
https://t.me/med1917
a. Progressive intervals of banjo practice.
b. Upright rows with resistance.
c. Cervical flexion active ROM.
d. Home cervical traction.
e correct answer is d. Home cervical traction. is
is the best choice of the provided options. Increasing playing
time may not provide much benefit without treating the
underlying impairments. ere is no indication of limited
strength that would support the prescription of upright rows,
and no information regarding limited cervical flexion ROM was
provided.
Case Scenario 3
Reilly is a 26-year-old dental student experiencing neck
pain after working on a particularly intensive tooth cleaning
procedure 1 week ago. Since then, the patient complains of
neck and mid-back pain, limited neck motion, and pain while
working in the clinic, which is rated as 5/10 on a numeric pain
rating scale. e past medical history is significant for obesity,
type II diabetes mellitus, and hypertension. e patient takes a
calcium channel blocker and an ace inhibitor for hypertension.
Reilly presents with limited segmental mobility throughout the
cervical spine, a negative upper limb tension test A, a negative
Spurling test, and 50% limitations in motion in all cervical
directions. Additionally, most cervicothoracic muscles have
limited flexibility.
1. Given this information, based on the Academy of
Orthopaedic Physical erapy neck pain clinical practice
guidelines, what impairment/function-based diagnostic
category does the patient fit into?
a.
Mobility deficits.
b. Cervicogenic headache.
c.
Movement coordination impairments.
d. Radiating pain.
e correct answer is a. Mobility deficits. e patient
largely presents with non-specific neck pain that is centralized
with segmental mobility deficits. She fits best into this category.
Factors that would place this patient in a different category are
absent.
2. Which of the following statements is true regarding central
posterior-to-anterior pressures in the cervical spine?
a. ey should always be performed in small, rapid
movements.
b. ey should be performed by the thumbs only.
c. ey can be both an assessment and an intervention.
d. ere is a high rate of side effects using this technique.
e correct answer is c. ey can be both an assessment
and an intervention. Once segmental mobility impairments
are identified, the physical therapist can proceed into treatment
using the same technique and applying grades of mobilization.
e evidence between manipulation and mobilization is
equivalent in the cervical spine. e speed and amplitude of the
technique is variable depending on your intention of mobility
versus pain modulation. While the technique is most commonly
performed with the thumbs, it is dependent on the therapists
and patient comfort as to how the technique is performed.
ere are generally few side effects from this technique.
Which intervention is best supported by evidence for Reilly
3.
according to the neck pain clinical practice guidelines?
a. Manual stretch of the upper trapezius muscle.
b. Deep neck flexor muscle endurance training.
c. Neurodynamic mobilizations.
d. oracic spine manipulation.
e correct answer is d. oracic spine manipulation.
Strong evidence exists supporting thoracic spine manipulation
for patients with acute neck pain with mobility deficits. While
the other options are plausible interventions, no specific
information in the case was provided regarding impairments
that would dictate these interventions.
4. Which of the following is true concerning a cervical upglide
manipulation?
a. e force is in an upward, distraction direction.
b. e force is directed toward the bottom of the plinth.
c. e cervical spine is rotated contralaterally.
d. A pre-manipulative hold is advised.
e correct answer is c. e cervical spine is rotated
contralaterally. Contralateral rotation and then side flexion
ipsilaterally is the setup for this technique. Pre-manipulative
holds are not advised for any cervical spine techniques. e
direction of force is in a rotation direction from the mobilizing
MCP towards the contralateral eye.
Case Scenario 4
Maureen is a 42-year-old professor. She has been receiving
physical therapy for neck pain following a motor vehicle
collision that occurred 3 months ago. While her symptoms
are mild, she exhibits several persistent deficits in her tolerance
to work activities, neck stiffness, and continues to experience
intermittent headaches about once per day.
1. Maureen’s physical therapist is considering manual therapy
techniques for the upper cervical spine and is curious about
risk of vascular dysfunction of the cervical spine. What
sign occurs most commonly during vertebral-basilar artery
dissection?
a. Nystagmus.
b. Diploplia.
46
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
c. Dysphagia.
https://t.me/med1917
d.
Ataxia.
e correct answer is d. Ataxia. Ataxia is not one of the
5Ds and 3Ns, although according to the 2020 IFOMPT CAD
Framework it occurs almost 70% of the time during vertebralbasilar artery dissection.
What is the best test to determine the cause of Maureen’s
2.
complaints of fatigue during work while on her computer?
Alar ligament test.
a.
b.
Anterior scalene muscle length test.
Deep neck flexors endurance test.
c.
Sternocleidomastoid muscle strength test.
d.
e correct answer is c. Deep neck flexors endurance test.
e fatigue is possibly caused by weakness in the deep neck
flexors. is finding would be consistent with a classification of
neck pain with movement coordination impairments. Neither
ligamentous insufficiency nor anterior scalene muscle tightness
will result in complaints of fatigue. If there had been ligamentous
insufficiency, the patient’s symptoms would likely not be mild.
e sternocleidomastoid muscle typically compensates for
weakness in deep neck flexors.
3. Maureen has made modest improvements in headache
frequency and neck pain over the past 3-months. What is
the prognosis for additional significant improvement from
physical therapy?
a. Minimal improvement likely.
b.
Moderate improvement likely.
Significant additional gains likely.
c.
Not enough data to determine.
d.
e correct answer is a. Minimal improvement likely.
Prognostic indicators suggest that the majority of improvement
in patients after motor vehicle collision who present with neck
pain occurs during the first phase of interventions and during
the first 3 months. Moving forward, only minimal additional
improvements are likely despite optimal treatment.
4.
Maureen presents with limited mobility in her lower cervical
spine and upper thoracic spine. What intervention would
not likely improve the mobility in this area?
Unilateral posterior-to-anterior mobilizations to C4-5.
a.
b.
First rib mobilization.
Seated thoracic manipulation.
c.
Contract-relax technique to the scalene muscles.
d.
e correct answer is a. Unilateral posterior-to-anterior
mobilizations to C4-5. is technique could provide improved
mobility at this segment, but it is not likely to cause improved
motion at the cervicothoracic junction unlike the other
techniques listed, which would all be more likely to do so. All
the other answers would improve mobility to the lower cervical
and upper thoracic regions.
1. Cook CE, Wilhelm M, Cook AE, Petrosino C, Isaacs R.
Clinical tests for screening and diagnosis of cervical spine
myelopathy: a systematic review. J Manipulative Physiol er.
2011;34(8):539-546. doi:10.1016/j.jmpt.2011.08.008
Cohen SP, Hooten WM. Advances in the diagnosis and
2.
management of neck pain. BMJ. 2017 Aug 14;358:j3221.
doi:10.1136/bmj.j3221
3. Cohen SP. Epidemiology, diagnosis, and treatment of neck
pain. Mayo Clin Proc. 2015;90(2):284-299. doi:10.1016/j.
mayocp.2014.09.008
4.
Bot SDM, van der Waal JM, Terwee CB, et al. Incidence and
prevalence of complaints of the neck and upper extremity
in general practice. Ann Rheum Dis. 2005;64(1):118-123.
doi:10.1136/ard.2003.019349
5. Genebra CVDS, Maciel NM, Bento TPF, Simeão SFAP,
Vitta AD. Prevalence and factors associated with neck pain: a
population-based study. Braz J Phys er. 2017;21(4):274-280.
doi:10.1016/j.bjpt.2017.05.005
6. Jette AM, Delitto A. Physical therapy treatment choices for
musculoskeletal impairments. Phys er. 1997;77(2):145-154.
doi:10.1093/ptj/77.2.145
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
REFERENCES
7. Jette DU, Jette AM. Physical therapy and health outcomes in
patients with spinal impairments. Phys er. 1996;76(9):930941; discussion 942-945. doi:10.1093/ptj/76.9.930
8. Blanpied PR, Gross AR, Elliott JM, et al. Neck Pain: Revision
2017. J Orthop Sports Phys er. 2017;47(7):A1-A83.
doi:10.2519/jospt.2017.0302
9. Kim R, Wiest C, Clark K, Cook C, Horn M. Identifying
risk factors for first-episode neck pain: A systematic review.
Musculoskelet Sci Pract. 2018;33:77-83. doi:10.1016/j.
msksp.2017.11.007
10. Fritz JM, Brennan GP. Preliminary examination of a proposed
treatment-based classification system for patients receiving
physical therapy interventions for neck pain. Phys er.
2007;87(5):513-524. doi:10.2522/ptj.20060192
11. Neumann DA. Kinesiology of the Musculoskeletal System:
Foundations for Rehabilitation. 2nd ed. Mosby/Elsevier; 2010.
12. Miller MB. e cervical spine: physical therapy patient
management utilizing current evidence. Wilmarth MA,
ed. ISC 21.2.6, Current Concepts of Orthopaedic Physical
erapy. 4th ed. La Crosse, WI: Orthopaedic Section, APTA;
2016.
47
13. Swartz EE, Floyd RT, Cendoma M. Cervical spine functional
https://t.me/med1917
anatomy and the biomechanics of injury due to compressive
loading. J Athl Train. 2005;40(3):155-161.
Tonetti J, Potton L, Riboud R, Peoc’h M, Passagia J-G,
14.
Chirossel J-P. Morphological cervical disc analysis applied
to traumatic and degenerative lesions. Surg Radiol Anat.
2005;27(3):192-200. doi:10.1007/s00276-004-0309-0
15. Nguyen C, Sanchez K, Roren A, et al. Anatomical specificities
of the degenerated cervical spine: a narrative review of clinical
implications, with special focus on targeted spinal injections.
Ann Phys Rehabil Med. 2016;59(4):276-281. doi:10.1016/j.
rehab.2015.12.006
16.
Teresi LM, Lufkin RB, Reicher MA, et al. Asymptomatic
degenerative disk disease and spondylosis of the cervical spine:
MR imaging. Radiology. 1987;164(1):83-88. doi:10.1148/
radiology.164.1.3588931
17. Tisherman R, Hartman R, Hariharan K, et al. Biomechanical
contribution of the alar ligaments to upper cervical
stability. J Biomech. 2020;99:109508. doi:10.1016/j.
jbiomech.2019.109508
18. Bransford RJ, Alton TB, Patel AR, Bellabarba C.
Upper cervical spine trauma. J Am Acad Orthop Surg.
2014;22(11):718-729. doi:10.5435/JAAOS-22-11-718
19.
OMPT Frameworks and Clinical Resources. Accessed January
31, 2021. https://www.ifompt.org/Research+and+Resources/
OMPT+Frameworks+and+Clinical+Resources.html
Aristokleous N, Seimenis I, Georgiou GC, Nicolaides A,
20.
Anayiotos AS. e effect of head rotation on the geometry and
hemodynamics of healthy vertebral arteries. Ann Biomed Eng.
2015;43(6):1287-1297. doi:10.1007/s10439-015-1340-5
21.
Waxenbaum JA, Reddy V, Bordoni B. Anatomy, Head and
Neck, Cervical Nerves. StatPearls Publishing; 2020. Accessed
January 18, 2021. https://www.ncbi.nlm.nih.gov/books/
NBK538136/
22. Bogduk N, Mercer S. Biomechanics of the cervical spine.
I: Normal kinematics. Clin Biomech. 2000;15(9):633-648.
doi:10.1016/s0268-0033(00)00034-6
Cook C, Hegedus E, Showalter C, Sizer PS Jr. Coupling
23.
behavior of the cervical spine: a systematic review of the
literature. J Manipulative Physiol er. 2006;29(7):570-575.
doi:10.1016/j.jmpt.2006.06.020
24. Coronado RA, Gay CW, Bialosky JE, Carnaby GD, Bishop
MD, George SZ. Changes in pain sensitivity following
spinal manipulation: a systematic review and meta-analysis.
J Electromyogr Kinesiol. 2012;22(5):752-767. doi:10.1016/j.
jelekin.2011.12.013
25.
Bialosky JE, Bishop MD, Penza CW. Placebo mechanisms of
manual therapy: a sheep in wolf’s clothing? J Orthop Sports
Phys er. 2017;47(5):301-304. doi:10.2519/jospt.2017.0604
26. Bialosky JE, Beneciuk JM, Bishop MD, et al. Unraveling
the mechanisms of manual therapy: modeling an approach.
J Orthop Sports Phys er. 2018;48(1):8-18. doi:10.2519/
jospt.2018.7476
27. Griswold D, Learman K, Kolber MJ, O’Halloran B, Cleland
JA. Pragmatically applied cervical and thoracic nonthrust
manipulation versus thrust manipulation for patients with
mechanical neck pain: a multicenter randomized clinical trial.
J Orthop Sports Phys er. 2018;48(3):137-145. doi:10.2519/
jospt.2018.7738
28. Young IA, Pozzi F, Dunning J, Linkonis R, Michener
LA. Immediate and short-term effects of thoracic spine
manipulation in patients with cervical radiculopathy: a
randomized controlled trial. J Orthop Sports Phys er.
2019;49(5):299-309. doi:10.2519/jospt.2019.8150
29. Puentedura EJ, Landers MR, Cleland JA, Mintken PE,
Huijbregts P, Fernández-de-Las-Peñas C. oracic spine thrust
manipulation versus cervical spine thrust manipulation in
patients with acute neck pain: a randomized clinical trial. J
Orthop Sports Phys er. 2011;41(4):208-220. doi:10.2519/
jospt.2011.3640
30. Maujean A, Gullo MJ, Andersen TE, Ravn SL, Sterling M.
Post-traumatic stress symptom clusters in acute whiplash
associated disorder and their prediction of chronic painrelated disability. Pain Rep. 2017;2(6):e631. doi:10.1097/
PR9.0000000000000631
31. Walton DM, Carroll LJ, Kasch H, et al. An overview of
systematic reviews on prognostic factors in neck pain:
results from the International Collaboration on Neck
Pain (ICON) project. Open Orthop J. 2013;7:494-505.
doi:10.2174/1874325001307010494
32. Sterling M, Kenardy J, Jull G, Vicenzino B. e development
of psychological changes following whiplash injury. Pain.
2003;106(3):481-489. doi:10.1016/j.pain.2003.09.013
33. Oostendorp RAB, Elvers JWH, van Trijffel E, et al. Clinical
characteristics and patient-reported outcomes of primary care
physiotherapy in patients with whiplash-associated disorders:
a longitudinal observational study. Patient Prefer Adherence.
2020;14:1733-1750. doi:10.2147/PPA.S262578
34. Elliott JM, Heinrichs BE, Walton DM, et al. Motor vehicle
crash reconstruction: Does it relate to the heterogeneity
of whiplash recovery? PLoS One. 2019;14(12):e0225686.
doi:10.1371/journal.pone.0225686
35. George SZ, Beneciuk JM, Lentz TA, et al. Optimal Screening
for Prediction of Referral and Outcome (OSPRO) for
musculoskeletal pain conditions: results from the validation
cohort. J Orthop Sports Phys er. 2018;48(6):460-475.
doi:10.2519/jospt.2018.7811
36. Stiell IG, Clement CM, McKnight RD, et al. e Canadian
C-spine rule versus the NEXUS low-risk criteria in patients
with trauma. N Engl J Med. 2003;349(26):2510-2518.
doi:10.1056/NEJMoa031375
37. Stiell IG, Wells GA, Vandemheen KL, et al. e Canadian
C-spine rule for radiography in alert and stable trauma
patients. JAMA. 2001;286(15):1841-1848. doi:10.1001/
jama.286.15.1841
38. Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin
C-WC. Accuracy of the Canadian C-spine rule and NEXUS
to screen for clinically important cervical spine injury in
patients following blunt trauma: a systematic review. CMAJ.
2012;184(16):E867-876. doi:10.1503/cmaj.120675
39. ACR Appropriateness Criteria. Accessed June 3, 2021. https://
www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria
40. Khan SN, Erickson G, Sena MJ, Gupta MC. Use of flexion
and extension radiographs of the cervical spine to rule
out acute instability in patients with negative computed
tomography scans. J Orthop Trauma. 2011;25(1):51-56.
doi:10.1097/BOT.0b013e3181dc54bf
41. Dwek JR, Chung CB. Radiography of cervical spine injury
in children: are flexion-extension radiographs useful for acute
trauma? AJR Am J Roentgenol. 2000;174(6):1617-1619.
doi:10.2214/ajr.174.6.1741617
42. Ross MD, Cheeks JM. Clinical decision making associated
with an undetected odontoid fracture in an older individual
referred to physical therapy for the treatment of neck pain. J
Orthop Sports Phys er. 2008;38(7):418-424. doi:10.2519/
jospt.2008.2687
48
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Соседние файлы в папке Библиотека им академика М.И. Перельмана