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% of 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  Progressive Tension 1. ○ 22, 24, 26, 28, 30 Elbow flexion and extension 2. GH Internal/external rotation 3. GH abduction and flexion/extension 4. Scapular protraction, depression, elevation 5. Diagonal patterns (PNF) 6.

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 of 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