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

Objective Exam • Palpation • Joint Mobility ▫ Tenderness with trigger ▫ Hypermobile body type points in: ▫ Hypomobility on L C - L scalenes 2/3, 5/6, 6/7, & T1 - L levator scapula ▫ L rotation in L upper - L upper and middle thoracic region trap ▫ Hypomobility in L - L upper cervical thoracic to PA spring region

Special Tests ULTT • Positive for median and radial nerve Cervical Distraction • Positive for symptom relief Spurlings • Positive with symptom reproduction

Outcome Measures NDI SPADI • 25/50 • Pain - 66% ▫ MDC: 5 points • Disability - 55% ▫ 0 - 4 = no disability • Total disability for L shoulder - ▫ 5 - 14 = mild 59% ▫ 15 - 24 = moderate ▫ MDC: 10% ▫ 25 - 34 = severe ▫ No disability= 0 ▫ above 34 = complete

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 with extension and Pain and heaviness in the - - - pain rotation, often bilateral cervical region and arms Pain, numbness, or tingling Pain can be gradual or acute Paresthesias (medial side of - - - in UE following a traumatic incident arm) UE weakness Posterior neck stiffness Aggravated by overhead - - - AGGs: prolonged Cervicogenic headache positioning of the arms - - sitting/reading, external or Possible pain referral to Intrinsic muscle deficit/atrophy - - lateral rotation of spine shoulder, scapular regions, and of hand EASEs: supine with head UE Easy fatigability, paleness, or - - and neck supported Often also complain of lumbar coldness of hand - facet problems 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

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

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

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