THE UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL … Notebook-Lectures-Labs 1.pdf · THE UNIVERSITY OF...

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THE UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS SOUTHWESTERN SCHOOL OF HEALTH PROFESSION ‐ DEPARTMENT OF PHYSICAL THERAPY

ORTHOPEDIC PHYSICAL THERAPY RESIDENCY EDUCATION CURRICULUM COURSES Course Name: Advanced Physical Therapy Practice: Clinical Orthopedic Residency Education Series

Weekend 2: Physical Therapy Management of the Cervicothoracic Region and TMJ Course Description: This is the first in a series of five courses designed to provide comprehensive, advanced training in manual therapy and orthopedic rehabilitation. This program will provide content specific to the Cervicothoracic region and TMJ using the framework of differential diagnosis, clinical reasoning, and treatment planning as introduced in Weekend 1. Program participants will receive hands‐on lab instruction in systematic examination testing essential for making pathology and impairment‐based diagnoses in the Cervicothoracic region and TMJ. They will also receive extensive hands‐on training in exercise and manual therapy techniques, including spinal thrust manipulation, for treatment of the Cervicothoracic region and TMJ. Instructional Level: Intermediate/Advanced Target Audience: Licensed Physical Therapists Behavioral/Learning Objectives: Behavioral and Instructional Objectives: At the completion of this course, the student will be able to: 1. Discuss key considerations regarding the anatomy and kinematics of the Cervicothoracic region

and TMJ as they contribute to pathology, movement analysis, and treatment planning 2. Gather all relevant information from the subjective and objective examination for making a sound

impairment and pathology‐based diagnosis in the Cervicothoracic region and TMJ 3. Perform detailed movement analysis of the Cervicothoracic region and TMJ for the purpose of

pathology and impairment‐based diagnosis 4. Perform special testing for the Cervicothoracic region and TMJ for the purpose of pathology‐based

diagnosis 5. Perform impairment‐based strength and flexibility testing of the Cervicothoracic region and TMJ 6. Perform manual techniques, including spinal thrust manipulation, to the Cervicothoracic region

and TMJ for the purpose of relieving pain and increasing mobility 7. Perform exercise techniques to the Cervicothoracic region and TMJ for the purpose of relieving

pain, increasing mobility, and increasing strength Directed Independent Learning Contact Hours: 5 On‐Site Contact Hours: 16 Total Contact Hours: 21 Course Coordinator: Jason Zafereo, PT, OCS, FAAOMPT Additional Lecturers: Julie DeVahl, PT, MS, OCS Lab Instructors: Jason Zafereo, Julie DeVahl, PT, MS, Ed Mulligan, PT, DPT, OCS, SCS, ATC, Emily Middleton, PT, DPT, CSCS

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Instructor Biographies:

Jason Zafereo, MPT, OCS, FAAOMPT (Lead Instructor) Mr. Zafereo is an Assistant Professor and Clinical Director of the faculty practice at UT Southwestern. Mr. Zafereo received his Bachelor of Arts in Biology from Baylor University and his Master of Physical Therapy from the University of Texas Southwestern Medical Center at Dallas. He received his fellowship training in orthopedic manual physical therapy from The Manual Therapy Institute. A board certified specialist in orthopedics, Mr. Zafereo’s clinical interests include orthopedic manual therapy with an emphasis in treatment of the neck and low back.

Julie DeVahl, PT, MS,OCS (Assistant Instructor and Independent Study Contributor) Ms. DeVahl is an Assistant Professor and the Director of Clinical Education at UT Southwestern. She received her B.S. in Physical Therapy from the University of North Dakota in 1979 and her Master of Science degree from the University of Minnesota in 1984. She joined the faculty of UT Southwestern department of physical therapy as the Director of Clinical Education in 2002. She has been teaching continuing education courses on electrotherapy topics throughout her career.

Beth Deschenes, PT, MS, OCS (Independent Study Contributor) Ms. Deschenes is a Clinical Assistant Professor at UT Southwestern and she received her Master of Science degree in Physical Therapy from the University of Kansas Medical Center in 1996. Prior to becoming a physical therapist, she worked in healthcare marketing and health/fitness management. Ms. Deschenes also holds a Master of Science degree in Health/Fitness Management from The American University, which she received in 1984. She was board certified in orthopedics since 2003.

Ed Mulligan, PT, DPT, OCS, SCS, ATC (Lab Assistant) Dr. Mulligan is an Assistant Professor in the Physical Therapy Department at UT Southwestern. His undergraduate degree is from the University of Nebraska and he received his physical therapy training at UTMB – Galveston. He completed the post‐professional master’s degree program at Texas Woman’s University‐Dallas in 1995 and his DPT at Regis University in 2008. He was recognized as a clinical specialist in sports physical therapy by the APTA in 1988 and orthopedic physical therapy in 2009.

Emily Middleton, PT, DPT, CSCS (Lab Assistant) Dr. Middleton is a Faculty Clinical Associate at UT Southwestern. She is the lead therapist at the department’s satellite sports medicine clinic on the UTD campus in Richardson, TX. Emily is a graduate of the UT Southwestern Orthopedic Physical Therapy Residency Program. She served as a lab assistant for a musculoskeletal spine curriculum and has been a speaker at the past two TPTA annual conferences.

Course Requirements:

1. 100% attendance is mandatory. 2. Students must be prepared and dressed appropriately for lab. Students MUST be able to expose

appropriate body parts for joint examination and intervention.

Required Reading/Pre‐Course Assignments:

On‐line Audiovisual Presentations: Cervical Anatomy/Kinematics/Pathoanatomy; TMJ Anatomy/Kinematics/Pathoanatomy; Thoracic Anatomy/Kinematics/Pathoanatomy Recommended References:

1. Magee, D. Orthopedic Physical Assessment. Elsevier, 2007, ISBN‐10: 0721605710 2. Flynn, T. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence‐Based Clinician.

Evidence in Motion, 2008, ISBN‐13: 9780971479234 3. Cleland, J. Orthopedic Clinical Examination: An Evidence‐Based Approach for Physical Therapists. Icon,

2005, ISBN‐10: 1929007876

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4. Cook C. Orthopedic Manual Therapy: An Evidence‐Based Approach. Prentice Hall, 2007, ISBN‐10: 0131717669

5. Butler D, Jones MA. Mobilisation of the Nervous System, Churchill Livingstone; 1991. ISBN‐10: 0443044007 6. Olson KA. Manual Physical Therapy of the Spine, Saunders; 2009. ISBN‐13: 9781416047490 7. Sahrmann, S. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, 2002, ISBN‐10:

0801672058 8. Dutton, M. Orthopaedic Examination, Evaluation, and Intervention. 2nd Ed. The McGraw Hill Companies,

Inc., 2008. ISBN‐13: 978‐0‐07‐147401‐6

Resources:

1. Description of Advanced Orthopedic Clinical Practice 2. AAOMPT/APTA Manual Therapy Guidelines 3. Bibliography and References Provided in Course Notebook

Means of Participant Course Evaluation:

1. Pre/Post Course self‐assessment of skill and knowledge 2. Course Evaluation and Feedback

Description of Teaching Methods and Learning Experiences:

1. Pre‐course on‐line audiovisual presentations 2. Lecture, Laboratory Demonstration, Practice, and Critique 3. Case Study Reviews 4. Question/Answer, Discussion, and Role Playing Opportunities 5. Direct observation and critique of skill during laboratory activities 6. Written and Live‐Patient Examinations (Residents only)

Course Agenda and Pre‐Course Audiovisual Presentations:

Content Instructors

Pre‐Course Cervical Anatomy/Kinematics/Pathoanatomy Deschenes

Pre‐Course TMJ Anatomy/Kinematics/Pathoanatomy DeVahl

Pre‐Course Thoracic Anatomy/Kinematics/Pathoanatomy Deschenes

Saturday Cervical Pre‐Course Review Discussion Zafereo

Cervical Examination Lecture Zafereo

Cervical Examination Lab Zafereo

Cervical Treatment Lecture Zafereo

Lunch

Cervical Treatment Lab Zafereo

TMJ Pre‐Course Review Discussion DeVahl

TMJ Examination/Treatment Lecture DeVahl

TMJ Examination/Treatment Lab DeVahl

Sunday TMJ Examination/Treatment Lab DeVahl

Thoracic Pre‐Course Review Discussion Zafereo

Thoracic Examination/Treatment Lecture Zafereo

Lunch

Thoracic Examination Lab Zafereo

Thoracic Treatment Lab Zafereo

Clinical Reasoning Practice Lab Zafereo

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Cervical Spine Applied Anatomy

Jason Zafereo, PT, OCS, FAAOMPT

Clinical Orthopedic Rehabilitation Education

Objectives

Discuss concepts relevant to pathophysiology and differential diagnosis for headache

Discuss concepts relevant to pathophysiology and differential diagnosis for cervical radiculopathy

Objectives

Discuss concepts relevant to pathophysiology and differential diagnosis for cervical disc and joint disorders

Discuss concepts relevant to pathophysiology and differential diagnosis for cervical instability

HEADACHE

Pathophysiology of Headache

Pain referred to TCN from structures innervated by the C1-3 spinal nerves

– Upper cervical synovial joints

– Upper cervical muscles

– C2-3 disc

– Dura mater of upper SC and posterior cranial fossa

Pain perceived based on higher center activity– Cortex

– Brainstem

Bogduk N, Curr Pain Headache Rep, 2001

Pathophysiology of Headache

Boyling et al., Grieve's Modern Manual Therapy: The Vertebral Column, 2005

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Differential Diagnosis of Headache (IHS)

Primary Headaches– Tension-type– Migraine– Cluster– Exertional

Other Headaches– Neuralgias– Central Facial Pain

Secondary Headaches

– Trauma

– Vascular

– Intracranial

– Substance/Withdrawal

– Infection

– Homeostasis

– Cervical/Cranial

– Psychiatric

Migraine Headache (IHS)

Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

Headache has at least two of the following characteristics:

– unilateral location

– pulsating quality

– moderate or severe pain intensity

– aggravation by or causing avoidance of routine physical activity

During headache at least one of the following:

– nausea and/or vomiting

– photophobia and phonophobia

Aura consisting of at least one of the following, but no motor weakness:

– fully reversible visual symptoms including positive features (eg, flickering lights, spots or lines) and/or negative features (ie, loss of vision)

– fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness)

– fully reversible dysphasic speech disturbance

Cluster Headache (IHS)

Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated

Headache is accompanied by at least one of the following:

– ipsilateral conjunctival injection and/or lacrimation

– ipsilateral nasal congestion and/or rhinorrhea

– ipsilateral eyelid edema

– ipsilateral forehead and facial sweating

– ipsilateral miosis and/or ptosis

– a sense of restlessness or agitation

Attacks have a frequency from one every other day to 8 per day

Occipital Neuralgia (IHS)

Paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third occipital nerves

Tenderness over the affected nerve

Pain is eased temporarily by local anesthetic block of the nerve

Dx Secondary Headaches

Pre-test likelihood (27%) pts presenting to ER

Presence of comorbidity*

Patient’s age > 50*

Existence of trigger factor*

Age > 60 with absence of pain in other body parts (neck/back) and diffuse headache of > 24 h duration

* 9.3 fold increased risk of secondary HA– Mert et al, J Headache Pain 2008

RADICULOPATHY

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Pathophysiology of Radiculopathy

Tension event associated with herniated intervertebral disc

Compression event associated with degenerative disc changes

– Zygapophyseal joint– Uncovertebral joint

Sizer et al, Pain Practice, 2001

Soft Herniation (C5/6 - C7/T1)

Degeneration occurs from the inside to outside (similar to lumbar discs)

Treatment focused on axial decompression

Irritated posterior longitudinal ligament leads to neck andarm pain

Pain with sagittal plane movements

Hard Herniation (C2/3 – C4/5)

Degeneration occurs from the outside to inside

Smallest A/P diameter and highest uncinate processes C4-6 (Ebraheim et al, Clin Orthop RelRes, 1997)

Treatment focused on A/P decompression

IVF stenosis creates isolated arm pain

Pain with foraminal closing

LOCAL CERVICAL PAIN

Pathophysiology of Local Cervical Pain

Disc disorders– Soft disc herniation

C5/6 and C6/7– Degenerative disc

disease Joint disorders

– Zygapophyseal joint– Uncovertebral joint

Differential Diagnosis of Disc Disorders

Soft disc herniation C5/6 and C6/7– Acute torticollis positional fault– Pain with sagittal plane motions primary – Pain with ipsilateral sidebending/rotation

secondary– Change with Repeated movements– Positive Dural tension testing

Degenerative disc disease– Diagnosis of exclusion– Reduced cervical lordosis– Pain with 3-D motion testing uncoupled

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Repeated Movements

McKenzie theory (Stevens and McKenzie 1988)

– Alteration of gelatinous nucleus position through loading of IVD

– Requires intact annulus

Alternate mechanism for effectiveness in cervical spine, possibly neurophysiological (Mercer and Jull 1996)

Dural Testing

Anchoring of C5-7 roots to sulcus of transverse processes decreases effectiveness of neural testing

Alternate mechanism for dural testing (Sizer et al 2001)

– Neck flexion with scapular retraction

– Tension on T1 root level

Differential Diagnosis of Joint Disorders

Zygapophyseal joint– Pain with 3-D motion

testing coupled– Primary restriction is into

rotation

Uncovertebral joint– Pain with 3-D motion

testing coupled– Primary restriction is into

sidebending

INSTABILITY

Pathophysiology of Instability

Degeneration and mechanical injury causes (Panjabi, J Spinal Disord, 1992)

– Poor posture

– Repetitive occupational trauma

– Acute trauma

– Weakness of cervical musculature

Increase in neutral zone of a spinal segment

Pathophysiology of Instability

Healthy versus microtrauma versus macrotrauma (Jull et al 2004)

– Excessive SCM activation in trauma groups during Craniocervical flexion

Chronic neck pain (Falla 2004)

– Decreased deep neck flexor activation with SCM overactivation

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Cervicothoracic Musculature

Global muscles– Upper trapezius/Levator– Splenius capitis/cervicis– Semispinalis capitis– SCM– Scalenes

Local muscles– Semispinalis cervicis– Multifidus– Longus colli/capitis (deep

neck flexors)

Differential Diagnosis Instability

Directional Susceptibility to Movement (DSM)

– Uni-planar motion Extension

Flexion

Rotation

– Combined motion Extension-Rotation

– Most common syndrome (Sahrmann 2011)

Flexion-Rotation


DSM into extension– History of whiplash

– Older patient

– Forward head/Increased thoracic kyphosis

– Pain/Hinge point with cervical extension

– Weak DNF/Thoracic extensors

– Stiffness thoracic extension, SCM, scalene


DSM into flexion– Exaggerated “correct” posture

– Younger patient

– Flat thoracic spine

– Pain with cervical flexion

– Weak intrinsic neck extensors

– Stiffness DNF and thoracic flexion


Scapula is the key for determining asymmetrical rotation forces on neck

Patients with rotation syndromes have pain/clicking during rotation/sidebending

Dominance of scapular elevators create global muscle overuse into the neck, which leads to inhibition of local muscles

Most common scapular impairment (Sahrmann 2002)– Scapular downward rotation

– Scapular depression

Scapular Downward Rotation/Depression Syndrome

Compensatory cervical extension with movements of upper extremity

– Levator scapula creates ipsilateral cervical rotation

– Upper trapezius creates contralateral cervical rotation

TOS

Shoulder impingement

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Impairments

Tight– Levator scapula* and

Rhomboid

– Pec minor

– Latissimus major and dorsi

Weak– Serratus anterior

– Lower and Upper* trapezius

Case Review



Objectives

Review concepts for history-taking, examination, and treatment planning in the context of a hypothesis-testing framework

Apply clinical reasoning process to orthopedic patient cases

Patient Cases

Data collection and hypothesis formation

Subjective exam– History of present illness

Onset, Location, Nature, Aggravating/easing, Intensity, Associated symptoms, Timing

– Functional status

– Medical History Co-morbidities, radiology, prior

treatment, patient goal(s)

Patient Cases

Hypothesis testing during objective exam and treatment

Objective exam– Impairment: ROM, Palpation for

position, Flexibility, MMT

– Pathology: ROM, Palpation for condition, Neurological exam, Special testing, Resisted testing

Treatment– Pain, Stiffness, Weakness

Patient Cases

Hypothesis categories– Pathology

Contractile/non-contractile

– Contributing factors Environmental, Behavioral, Emotional, Physical,

Biomechanical

– Contraindications/precautions

– Prognosis Co-morbidities, Flags, Healing phase, Exam findings

– Management Yellow flags, Pain, Stiffness, Weakness, Education

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Assignment

Pick a partner

Pick case 1-2 or 3-4

Assign roles of patient/therapist

Therapist: interview, pre-exam pathology hypothesis, verbal exam, post-exam hypotheses (including treatment)

Switch roles/cases

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Cervical Spine Differential Diagnosis



Objectives

Describe the relevant findings from the history and examination consistent with a contractile tissue source of symptoms

Describe the relevant findings from the history and examination consistent with a non-contractile tissue source of symptoms

Objectives

Describe the relevant findings from the history and examination consistent with stiffness as a primary impairment to movement

Describe the relevant findings from the history and examination consistent with instability/weakness as a primary impairment to movement

CONTRACTILE TISSUE PATHOLOGY

Myofascial Pain Syndrome

55% of head and neck pain cases (Fricton et al 1985)

95% of chronic cases 95% of chronic cases referred to pain management (Gerwin 1995)

41% of new patients (over a 5-month period) referred to otolaryngologist practice (Teachey 2004)


Elevation of contractile substancessubstances

– Acetylcholine

– Calcium

Hypoxia and low pH

Contraction knots– Contracted

sarcomeres

Sensitization Travell and Simons 1999

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Trigger Points (TrPs)

Active– Spontaneous pain

at rest

Latent– No

spontaneous

– Pain on contraction or stretching of muscle involved

– Mirror image motor unit activation in 61.5% patients with chronic neck pain (Audette et al 2004)

ppain at rest

– May have pain on contraction or stretching

– No mirror image activation

Subjective Exam Findings

Nature– Aching, cramping, difficult to localize and

referred to deep somatic tissues

Associated symptoms– Affective-emotional pain component w/

heightened attention to painful stimuliMyofascial connection to anterior cingulate

cortex/ periaquaductal gray (PAG)

– Headache


TrPs present in 93.9% of migraineurs, 29% of asymptomatic controls (Calandre et al 2004)

Migraine location consistent with site of TrP referral from temples, suboccipitals (Giamberardino et al 2007)

Location of TrPs in TTHA– UT 75%

– Temporalis 74%

– SCM 60%


Tension type headache has at least two of the following characteristics (IHS):

– bilateral locationbilateral location

– pressing/tightening (non-pulsating) quality

– mild or moderate intensity

– not aggravated by routine physical activity such as walking or climbing stairs

Plus, both of the following: – no nausea or vomiting (anorexia may occur)

– no more than one of photophobia or phonophobia

Subjective Exam Findings--Location

Travell and Simons 1999



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B involvement in fibromyalgia/ sensitizationsensitization

Multiple active TrP sites in UTs (7.4/13), particularly mid-belly of muscle, compared to 0/13 active in normal controls– Ge et al 2009

Objective Exam Findings

Test Response

ROM/Flexibility Restricted flexibility of involved muscle; Active and Passive ROM painful in opposite directions; CROM t i ifi tl li it d t ithCROM not significantly limited except with Levator and Splenius Cervicis TrPs

Muscle Provocation Testing Painful, possibly weak (no atrophy)

Palpation 1) Focal tenderness with concordant sign reproduction (about 3kg of pressure)

2) Twitch response3) Taut band4) Often referred pain (non dermatomal) on

continued (~5sec) pressure


Palpation reliability– Inter-rater reliability upper torso, k=0.74 (Gerwin et al

1997)1997)

– Intra-rater reliability upper trap, ICC=.61-.82 (Barbero et al 2012)

– Inter-rater reliability upper trap Experienced, k=.63

Inexperienced, k=.22– (Myburgh et al 2011)

NON-CONTRACTILE TISSUE PATHOLOGY

Nerve

Interface sites– Disc

(protrusion/prolapse)(protrusion/prolapse)

– IVF (reduced AP diameter)


Demographics– <45 years (disc)

– >45 years (IVF)

Nature– Sharp, shooting, linear,

catching45 years (IVF)

Aggravating– Nerve tension positions of

neck or UE

– Coughing/sneezing/straining (disc)

– Closing positions neck (IVF)

Intensity– High severity and irritability

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Easing (meds)– Less responsive to

NSAIDs, more to anti-epileptic (Neurontin-Lyrica) or anti-depression (Amitriptyline) meds

Associated neuro sx

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Subjective Exam Findings--Location Objective Exam Findings

Test Response

ROM UE: Active and Passive ROM equal and painful in same direction; Cervical spine painful in same direction; Cervical spine rotation <60deg (IVF); Changes with repeated movements (disc)

Special Testing Positive Cervical distraction; positive Spurling’s; Positive ULTT

Neurological exam Sensation, strength, and reflex may be altered at key sensory/motor points

Palpation Tenderness over nerve trunks and involved segment

CPR for Cervical Radiculopathy

Key Tests (Wainner et al 2003)– ULTT

(K=.76, LR+=3.5, LR-=.58)(K .76, LR 3.5, LR .58)

– Spurling’s test

(K=.60, LR+=3.50, LR-=.58)

– Distraction test

(K=.88, LR+=4.40, LR-=.62)

– Cervical rotation <60deg

Cluster– 3/4 positive, +LR = 6.1 (65%)– 4/4 positive, +LR = 30.3 (90%)

Joint/Disc

Pain of joint/disc origin can be hard to distinguish

– Pathology specific examPathology specific exam usually not helpful

– ROM exam serves as primary means of identification

Diagnosis of exclusion after ruling out nerve/muscle with pathology-specific exam

Subjective Exam Findings--Disc

Age– 30-45 years old

Onset– Chronic, history of acute torticollis

Nature– Aching

Associated symptoms– May report pain with swallowing

Subjective Exam Findings—Disc Location

C3/4– Mastoid, temple, TMJ, Parietal cranium

C3/4 to C5/6 C3/4 to C5/6– Occipital cranium, OA, Neck, Throat

C3/4 to C6/7– Upper back, trapezius, Superior shoulder, UE

C4/5 to C6/7– Anterior chest

C6/7– Scapula

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Subjective Exam Findings-Cervicogenic Headache (IHS***)

Dull, not throbbing or lancinating***

Unilateral, in ram’s horn distribution (may project to forehead orbits) ***forehead, orbits)

HA affected by cervical ROM/posture ***

Migraine meds not helpful

Largely female, mean age at onset 33-43

History of trauma

No significant nausea, phot/phon-ophobia, vertigo

Subjective Exam Findings- Joint Location

Dwyer et al 1990; Fukui et al 1996


Test Response

ROM Active and Passive ROM painful in same pdirection***; Sagittal plane: Disc; Frontal plane:UVJ; Transverse plane: Joint/Disc;Repeated movements: Disc

Special Testing (Disc) Cervical flexion with scapular retraction

Special Testing (HA) Limited Cervical Flexion Rotation Test;Decreased performance on Craniocervical Flexion Test

Palpation Tenderness over involved joints***

Diagnostic Accuracy of Special Testing

FRT– Positive: ROM ≤32deg is

significantg

– 91% sens, LR-=.09; 90% spec, LR+=9.32 (Ogince et al 2007)

– 63% C1/2 involvement in CGH (Hall et al 2010)

CCFT (Jull et al 2007)– Limited performance 26-

30mmHg

– 100% sens, 94% spec when combined with ROM, palpation findings

PRIMARY STIFFNESS IMPAIRMENT


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Objective Exam Variable Response

ROM Limited ROM

Passive physiological movement Capsular pattern; characteristic motion loss with firm end feel

Passive accessory movement R1 occurs before P1

Palpation/Observation Tenderness, tightness, and presence of positional fault (TP/facet rotation/scapula)

Flexibility Limited in muscles prone to hypertonicity

Cervical Alignment Testing StabilityData from Normal 20-year Olds

Forward HP (ICC = 0.82 - 0.91; SEM = 1.42° - 1.70°) and side flexion (ICC = 0.63 - 0.85; SEM = 0 83° 1 27°) t bl ithi0.83° -1.27°) were stable within a session, within a day, and over a 7-day period, regardless of time of day for testing

Head extension was found to be less stable (ICC = 0.71 - 0.83; SEM = 2.69° - 3.72°)

Average position = -0.15° (side flexion) and 50° (forward HP)

Abnormals vary by 2.2° - 6.7° for Forward HP

Silva et al, Physiotherapy Theory and Practice, 2011)

Cervical ROM Diagram

RL

RL

Cervical Cardinal Plane Patterns

Upper Cervical Cardinal Plane Testing

OA flexion/extension C1/2 rotation

Reliability of Motion Testing

Physiological– Mobility K = .78 to 1.0

for C0 C3for C0-C3 Jull et al, Aust J

Physiother, 1997

– Mobility K =.03-.63 for C2-T2 (PA or 1-D tests)

– Pain ICC =.22-.80 for C2-T2 (PA or 1-D tests) Pool et al, J Manip

Physiol Ther, 2004

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Seated cervical sidebend test (with 3-D coupled motion) C2-3 tocoupled motion) C2 3 to C6-7

Assess pain provocation, hypomobility, end feel

K = Fair to moderate most painful side

K = Fair to substantial least painful side

– (Manning et al 2012)

Common Motor Patterns

Ventral hyperactive musculature

– Pec minorPec minor

– Scalenes

– SCM

– Biceps

Dorsal hyperactive musculature

– Middle and upper trapezius

– Levator scapulae

Flexibility Testing

Traditional, passive length assessment

versus

Active dominance assessment– Upper trap dominance creates

ipsilateral C2 SP movement with UE elevation

– Levator dominance creates contralateral C2 SP movement with UE elevation

PRIMARY WEAKNESS IMPAIRMENT


Subjective Exam Variable Response

Mechanism Remote history of trauma; frequentMechanism Remote history of trauma; frequent episodes of acute attacks

Aggravating factors Sustained weight-bearing posture; sharp pain with sudden movements

Easing factors Manipulation; Non-weight bearing; external support (hands and collar)

Associated factors Popping, clicking, lockingFatigue and inability to hold head up


Objective Exam Variable Response

Active movements Full general mobility with painful arc; aberrant motion; hinging, pivoting, abe a t ot o ; g g, p ot g,fulcruming. Greater ROM in supine than in sitting/standing

Passive physiological movement Full with decreased resistance to end range

Passive accessory movement Increased neutral zone

Strength testing Weakness/poor coordination longuscolli/capitus

Palpation Atrophy of multifidus segmentally

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Dorsal hypoactive musculature

– Lower trapezius

– Serratus

– Supra- and infraspinatus

– Deltoid

– Triceps

Ventral hypotonic musculature

– Deep neck flexors

Strength Testing

Trapezius– Lower: Association

between low trap pweakness and side of neck pain (Petersen and Wyatt, 2011)

– Upper: Standing shrug with UEs overhead (Sahrmann 2002)

Strength Testing

Serratus Anterior– Position: Seated, shoulder

120-130deg. Resistance gat upper arm downward and backward

– Normal: Holds scapular abduction/upward rotation

– Considerations: Pec minor and levator substitution

Details on Craniocervical Flexion Test (Jull et al 2004)

Procedure– Stabilizer to 20mmHg

Chi d i h– Chin nod without superficial activity

– 10sec x 10

Test results– Normal = 26 mmHg

– Ideal = 26-28 mmHg

Details on Neck Flexor Endurance Test

Procedure– Max chin retraction

– Lift head 1in above plinthLift head 1in above plinth

Test results (Harris et al 2005)

– Mean without neck pain = 38.95s

– Mean with neck pain = 24.1s

Significant effect of gender (not age/activity) in normals (Domenech et al 2011)

– Men = 38.9s

– Women = 29.4s

Deep Neck Flexor Assessment

CSA of DNF group (McGaugh and Ellison, 2011)

– Moderate-good ICC intrasession reliability

M d ICC i li bili– Moderate ICC interrater reliability

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Deep Posterior Neck Muscle Assessment

Semispinalis cervicis, multifidus, and rotatores imaged togetherimaged together

CSA=2.6 (f) - 3.15 (m) cm2

Age, gender (normalized to BMI) not associated with muscle size differences

Asymmetry >8% could be indicative of pathology, best evidence in chronic WAD

– Rankin et al, 2005

Cervical Examination Lab

I. Palpation/observation for position

a. Head: Chin in line with sternum; Ear over shoulder

b. Neck: Torticollis, Lordosis, Hinge points

c. Scapula: 3 inches from thorax, medial border parallel to spine, T2‐7, 30deg anterior tilt

d. Shoulder: Slightly below horizontal axis of T1; central acromium at midaxillary line

II. ROM testing a. Cardinal plane movements (AROM) with Overpressure (PROM)

i. Isolated upper cervical movements 1. OA flexion/extension in maximum end range rotation 2. C1/2 rotation in maximum end range flexion

ii. Whole cervical movements (25, 50, 75% limited)

b. Quadrant tests (3‐D movement primarily affects posterior spinal elements) i. Combined flexion with contralateral sidebend/rotation ii. Combined extension with ipsilateral sidebend/rotation

c. Repeated movements i. Retraction with posterior glide/Protraction with anterior glide ii. Foraminal opening with posterior glide

d. Shoulder screen i. ROM and affect on concordant sign ii. Bakody’s sign: reduced C4‐6 radiculopathy pain with hand on head

OA ROM Flexion with overpressure Sidebend with overpressure

C1/2 ROM Extension with overpressure Rotation with overpressure

Closing quadrant Re/Pro‐traction Foraminal opening Bakody’s sign

III. Flexibility testing

a. Upper trapezius

i. Maximally sidebend neck with contralateral scapula in elevation. Depress

contralateral scapula. Cervical sidebending should remain constant.

ii. C2 SP moves toward arm (UT tight) with UE elevation

b. Levator scapula

i. Maximally flex and contralaterally sidebend rotate neck. Maximally abduct arm

on side of testing. Arm should touch the head without losing any cervical

sidebending.

ii. C2 SP moves away from arm (levator tight) with UE elevation

IV. Strength testing

a. DNF

i. Craniocervical flexion test

1. Stabilizer to 20mmHg

2. Target 22‐30mmHg

3. Criteria for test termination: inability to hold 10secs and repeat 10x at a

level

4. Goal ≥ 26mmHg

ii. Neck flexor endurance test

1. Cranium in max retraction, 1inch off table

2. Criteria for test termination: Loss of chin retraction

3. Goal ≥ 30secs

V. Palpation for condition

a. Myofascial pain syndrome

Upper trap flex. Levator flex. C2 stability

CCFT Neck flexor endurance

i. Assess tissue sliding using flat fingertip palpation

ii. Assess tissue splay using pincer palpation

iii. Assess taut bands/trigger points using deep pressure fingertip palpation

VI.

VII. Joint mobility testing

a. OA

i. Flexion 10deg to Extension 30deg

1. Move through sagittal plane on axis through ears

ii. Sidebending 5‐15deg

1. Move through frontal plane on axis through nose

iii. Sidegliding

1. Flex head up to lock out lower cervical spine. Glide side to side.

2. Expect limitations opposite OA sidebend limitations

b. C1/2

i. Maximum cervical flexion with bilateral rotation ≥ 32deg (AKA Flexion‐Rotation

Test)

ii. Maximum cervical sidebending with contralateral rotation

1. Important to maintain head in line with neck while rotating (ex: apply

right sideglide at C2 while testing right rotation)

iii. Unilateral PA articular pillar of C2 with head turned 30‐40deg ipsilateral rotation

OA flexion/extension OA sidebending OA sidegliding

Flexion‐Rotation Test C1/2 phys. Rotation C1/2 PA

Tissue sliding Tissue splay Taut bands

c. C2‐7

i. Sideglide

1. Position hands in cradle around the neck. Contact articular pillars with

palmar MCPs. Apply pressure through MCPs. Glide side to side

2. Closing restriction: Loss of contralateral sideglide, more limited in

extension

3. Opening restriction: Loss of ipsilateral sideglide, more limited in flexion

ii. PA

1. Contact SP or Facet with B thumbs or “dummy thumb”

2. Glide P to A in plane of facet

3. Assess size of neutral zone and resistance at end range

iii. 3‐D PPIVM

1. Contact articular pillar with radial DIP

2. Assess folding (collapse) of segmental level with closing quadrant

3. Compare level to level, assessing for pain and loss of movement

VIII. Upper Quadrant Neurological Testing 1. DTRs

a. Testing sites i. C5‐biceps ii. C6‐brachioradialis iii. C7‐triceps

b. Outcomes i. Increased‐Segmental facilitation or central compression ii. Decreased‐Root compression

2. Sensation (pin prick) a. Testing sites

i. C4‐shawl area ii. C5‐lateral deltoid/lateral elbow iii. C6‐posterior thumb iv. C7‐posterior distal middle finger

Sideglide hand position Sideglide application Central PA 3‐D PPIVM

v. C8‐lateral border of little finger vi. T1‐medial forearm vii. T2‐axilla

b. Outcomes i. Increased‐Segmental facilitation ii. Decreased‐Central or root compression

3. Strength a. Testing sites

i. C4‐scapular elevation (trapezius) ii. C5‐deltoid iii. C6‐biceps/wrist extension iv. C7‐triceps/wrist flexion v. C8‐thumb extension vi. T1‐finger abduction/adduction

b. Outcomes i. Decreased without fatigability‐ Segmental facilitation ii. Decreased with fatigability‐Central or root compression

4. Peripheral nerve tests a. Radial nerve

i. Resisted wrist extension b. Median nerve

i. Resisted DIP flexion of index finger (OK sign) c. Ulnar nerve Resisted abduction of index finger (lateral key pinch)

IX. Special testing

a. Spurling’s

i. Ipsilateral sidebending with axial

compression (A)

ii. Ipsilateral closing quadrant with axial

compression (B)

b. Distraction

i. Seated or Supine, ensure patient relaxation

c. Dural tension test

i. Neck flexion with scapular retraction

ii. Positive: Concordant sign reproduction more pronounced with retraction

Spurling’s A Spurling’s B

Distraction supine Distraction seated Dural tension test

d. ULTT

i. ULTT 1 (median nerve)

1. Scapular depression

2. GHJ ABD to 110deg

3. Forearm supination

4. Wrist and finger extension with radial

deviation

5. GHJ ER

6. Elbow extension

7. Cervical sidebending

ii. Normal findings (ULTT 1)

1. Deep Stretch or ache in cubital fossa extending down the anterior and

radial aspects of the forearm and in the radial hand

2. Definite tingling sensation in the thumb and first three fingers

3. Stretch in anterior shoulder area

4. Increased symptoms with contralateral cervical sidebending

5. Decreased symptoms with ipsilateral cervical sidebending

6. Range of elbow extension deficit 16.5‐53.2deg

iii. ULTT 2a (median nerve)


2. GHJ ABD to 10deg

3. Elbow extension

4. GHJ ER

5. Wrist and finger extension with radial

deviation

6. Increase GHJ ABD 40‐50deg or Cervical

sidebending

iv. ULTT 2b (radial nerve)


2. GHJ ABD to 10deg

3. Elbow extension

4. GHJ IR

5. Wrist and finger flexion with ulnar deviation

6. Increase GHJ ABD 40‐50deg or Cervical

sidebending

v. ULTT 3 (ulnar nerve)


2. Forearm supination

3. Wrist and finger extension with radial deviation

4. Elbow flexion

5. GHJ ABD to the point of placing patient’s hand over ear

6. Cervical sidebending

X. Craniovertebral Scan

1. Cervical Myelopathy

a. Pathological reflexes i. Babinski

1. Pointed object run along lateral to medial sole of foot 2. Positive: Extension of big toe and splaying of other toes

ii. Hoffman’s Test (K=.76, Cook et al, JOSPT, 2009) 1. Flick patient’s middle finger 2. Positive: Flexion pattern of index finger and thumb

iii. Inverted supinator sign 1. absence of contraction of the brachioradialis muscle when the styloid

process of the radius is tapped 2. hyperactive response of the finger flexor muscles

iv. Pathological reflexes, gait deviation, and age >45 years (3/5 positive: +LR=30.9; 1/5 positive: ‐LR=.18) Cook et al, JMMT, 2010

b. Brisk DTRs‐UE/LE (K=.68) c. Clonus of wrist or ankle

i. Positive: Greater than 3 beats or sustained activity d. Lhermitte’s sign

i. Long sitting, passive flex patient’s head and one hip ii. Positive: Sharp, electric shock pain in spine or extremities

e. Romberg’s Test i. Patient standing with eyes closed for 20‐30secs ii. Positive: Excessive sway or loss of balance

2. Cervical Spine Fracture/Instability a. Canadian C‐spine Rule (Spec 42.5%, Sens 100%), Stiell et al, JAMA, October 2001

i. Imaging required 1. High risk: Age>65 or dangerous mechanism or paresthesias in

extremities ii. No imaging required

Babinski Hoffman’s Inverted Supinator Lhermitte’s

1. Low risk: Simple rear‐end collision or able to tolerate sitting position in ER or ambulatory at any time after onset or delayed onset of neck pain or absence of mid line cervical spine tenderness

and 2. ROM: At least 45deg rotation each direction

b. Jefferson Fracture Test i. Medial pressure on TP of C1 while stabilizing opposite TP ii. Positive: Movement or crepitus or cardinal symptoms

c. Alar Ligament Test i. Patient seated, palpate C2 while sidebending patient’s head ii. Normal: Immediate movement of C2 opposite of sidebending

d. Transverse Ligament Test i. Patient supine, palpate C2. Move occiput and C1 anteriorly on C2. Hold 20sec ii. Normal: C2 should follow, no cardinal symptoms

e. Sharp‐Purser Test (Spec 96%, LR+=17.25, Sens 69%, LR‐=.32), Uitvlugt et al, Arthritis &

Rheumatism, July 1988

i. Patient seated, hand on forehead, finger pressing in on C2 SP. Passively flex head while pressing occiput posteriorly

ii. Positive: Reduction of atlas on axis

3. Vertebral artery Insufficiency

a. Vertebral artery Test (Sens 9.3%,Spec 97.8%, LR+=4.2) Sakaguchi et

al, Neurology, Sept 2003

i. Head and neck in closing quadrant, hold up to 30secs ii. Positive: 5 Ds or Nystagmus

b. Hautant’s Test i. Patient seated with arms flexed to 90deg, eyes closed.

Hold up to 30secs. c. Results: Arms move with head in neutral, nonvascular (articular);

arms move with head in closing quadrant, vascularCranial nerve testing

i. CN 2‐optic‐visual acuity ii. CN 3, 6‐occulomotor, abducens‐look up and out iii. CN 4‐trochlear‐look down and in iv. CN 5‐trigeminal‐facial sensation v. CN 7‐facial‐smile/frown

Alar Ligament Transverse Ligament Sharp‐Purser

Hautant’s

vi. CN 8‐vestibulocochlear‐hearing/body tilt vii. CN 9‐glossopharyngeal‐ gag reflex viii. CN 10‐vagus‐elevation of soft palate with “ah” ix. CN 11‐spinal accessory‐upper trapezius strength x. CN 12‐hypoglossal‐tongue movements

1

Cervical Spine Management



Objectives

Discuss the components of a classification scheme as proposed by Childs et al.

Describe the treatment interventions used for the management of pain from contractile and non-contractile tissue sources

Objectives

Describe the treatment interventions used for the management of stiffness from contractile and non contractile sourcesand non-contractile sources

Describe the treatment interventions used for the management of instability of non-contractile sources

Describe treatment considerations for post-op ACDF

TREATMENT-BASED CLASSIFICATION

“Old” Classification Categories

Treatment-based system (Childs et al 2004)– Pain-dominant treatment

Acute pain/WAD Acute pain/WAD Headache Radiculopathy

– Impairment-dominant treatment Mobilization Exercise and conditioning

“New” Classification Categories

ICF-based system (Childs et al, JOSPT 2008)– Pain-dominant treatment

Neck pain with headaches Neck pain with headaches Neck pain with radiating pain

– Impairment-dominant treatment Neck pain with mobility deficits Neck pain with movement coordination impairments

2

Category Characteristics

Acute Pain/WAD – Onset by MVA

D ti f <30

Re-distributed among– Neck pain with mobility

deficits– Duration of sx <30 days

– Initial pain rating >7 or NDI>52

– ~6% of cervical population Fritz et al 2007

deficits

– Neck pain with movement coordination impairments Childs et al 2008


Headache– CC HA with neck pain– HA affected by

movement

Neck pain with headaches– Unilateral HA associated with

neck/suboccipital area symptoms movement

– No dx of migraines– No WAD– No radiating sx below

elbow– ~9% of cervical

population Fritz et al 2007

that are aggravated by neck movements or positions

– Headache produced or aggravated with provocation of ipsilateral posterior cervical myofascia and joints

– Restricted cervical ROM/segmental mobility

– Substandard performance on cranial cervical flexion test Childs et al 2008


Radiculopathy– Signs of nerve

root i

Neck pain with radiating pain– Upper extremity symptoms, usually

radicular or referred, pain, that are compression

– Sx distal to the elbow

– No WAD– ~35% of

cervical population Fritz et al

2007

produced or aggravated with Spurling’s maneuver and upper limb tension tests, and reduced with the neck distraction test

– CROM rotation <60° ipsilateral

– Signs of nerve root compression

– Success with reducing UE symptoms with initial examination and intervention procedures Childs et al 2008


Mobilization– Duration of sx <30days– Age <60

Neck pain with mobility deficits– Duration <12 weeksg

– No WAD– No radiating sx below

elbow– ~ 18% of cervical

population Fritz et al 2007

– Age <50– Symptoms isolated to

the neck– Restricted cervical

ROM Childs et al 2008


Exercise and conditioning

– Duration of sx >30days

Neck pain with movement coordination impairments

– Duration of sx >12 weeks– Substandard performance on cranialy

– Age >60– No WAD– No radiating

sx below elbow

– ~33% of cervical population Fritz et al

2007

Substandard performance on cranial cervical flexion test and deep neck flexor endurance test

– Coordination, strength and endurance deficits of neck and and upper quarter muscles (longus colli, middle trapezius, lower trapezius, serratus anterior)

– Flexibility deficits of upper quarter muscles (anterior/middle/posterior scalenes, upper trapezius, levator scapulae, pec minor, pec major)

– Ergonomic inefficiencies with repetitive activities Childs et al 2008

PAIN-DOMINANT TREATMENT

3

Pain-Dominant Treatment

Mixed tissue-type– Acute/Chronic WAD

– Neck pain with headachesNeck pain with headaches

– Torticollis

Contractile– Myofascial pain syndrome

Non-contractile– Neck pain with radiating pain

Acute WAD Management

General guidelines– Relative rest

Intermittent cervical collar– Intermittent cervical collar – Physical modalities

Tissue specific guidelines– Graded AROM (with directional pref) – Graded mobilization (with directional pref)– Submaximal isometrics– Soft tissue massage

# Active TrPs related to loss of CROM and pain intensity (Fernandez-Perez et al. 2012)

Acute WAD Management

Contributing Impairments– Emotional/Behavioral/Physical (Poor Px variables)

Hi h l l f i /NDI ( 5 5/10 14 5/50) HA t High levels of pain/NDI (>5.5/10, >14.5/50), HA at inception, < postsecondary education, female, and WAD grade 2 or 3 (Walton et al 2013)

Cold hyperalgia (Goldsmith 2012)

– Mechanical TSM (Fernandez de las Penas et al 2004)

– 40% VAS reduction and increased rotation by 20° (4th visit)

DNF strengthening to address underlying instability (often Sahrmann extension syndrome)

Scapular stabilization/passive support

Chronic WAD Characteristics

Central sensitization– Signs and symptoms

Wid d t i l i di t ib ti Widespread, non-anatomical pain distribution

Hypersensitivity to pressure pain threshold, touch, vibration, temperature, mental load

Chronicity, failed conservative treatment

Unresponsive to NSAIDs

Disproportionate/inconsistent response to movement

More constant/intense/irritable pain, including night pain

Strong association with maladaptive psychosocial factors

Nijs et al 2010

Chronic WAD Management

Multidisciplinary pain program

– Pain versus time-Pain versus timecontingent treatment

– Specific stabilization exercise*

– Low velocity mobilization*

– Ergonomic education*

– Psychosocial intervention program

*Jull et al 2007; Nijs et al 2009

Neck pain with HeadacheManagement

Contractile (TTHA)– Soft tissue mobilization/massage

– Relaxation (Breathing, Direct/Indirect muscleRelaxation (Breathing, Direct/Indirect muscle energy techniques)

– Needling (Karakurum et al 2001)

– Conventional TENS (Ahmed et al, Headache 2000)

Non-contractile (Cervicogenic)– Graded mobilization (C0-C3)

– Graded ROM Cervical spine directional pref or restricted ROM

Neural gliding PRN

4

Neck pain with HeadacheManagement

Contributing Impairments– Environmental/Emotional

Sitti t di l i k Sitting, standing, sleeping, work ergonomics

Stress management (TTHA)

– Mechanical Underlying joint dysfunction

(Cervicogenic)

Facilitated segment (TTHA)

DNF strengthening (Cervicogenic)

Scapular stabilization/TSM

Support for Headache Management

Contractile (Hammill et al 1996)– 2 visits for ergonomics and HEP instruction for cervical

stabilizer strengtheningg g

– 4 visits for massage and stretching

– Significant improvement compared to control

Non-contractile (Jull et al 2002)– Comparison of mobilization, neck and scapular stabilization,

combined treatment, and control

– Significant improvement in individual and combined groups; greater proportion of good to excellent results in combined group


General guidelines– High freq/intensity TENS (Graff-Radford et al 1989)

– Iontophoresis with lidocaine (Kaya et al 2009)Iontophoresis with lidocaine (Kaya et al 2009)

– Laser (Kannan 2012)

– Thermal ultrasound (Srbely and Dickey 2007)

Tissue specific guidelines– Soft tissue mobilization/massage (Sefton et al 2011)

Improved CROM/decreased EMG activity compared to light touch or control

– Relaxation (Breathing, Direct/Indirect METs)

– Needling local or remote (Tsai et al 2010) Improved CROM and UT pain with needling at ECRL


Contributing Impairments– Environmental/Emotional/Physical

Sitting standing sleeping work ergonomics Sitting, standing, sleeping, work ergonomics

Stress, increased sympathetic output, fatigue

Hormone (estrogen/thyroid) deficiencies

Vitamin and mineral deficiencies

– Mechanical Treatment of underlying facilitated segment

– C3-4 dysfunction associated with TrPs in UT, SCM, LS (Fernandez de las Penas 2009)

Synergist/agonist strengthening

Thoracic Spine Manipulation

Torticollis Management

Noncontractile Disc– Graded Axial distraction

– Graded ROM (into

Noncontractile Joint– Graded mobilization

Direct isometric Graded ROM (into directional preference)

Contractile SCM– STM and MET

mobilization

Indirect manipulation

Webb et al 2011

Torticollis Management

Contributing Impairments– Environmental

E i t i d d d Ergonomics on sustained and end range postures

– Mechanical Treatment of underlying instability

Mobilization of hypomobile segments above/below level

5

Neck pain with Radiating PainManagement

General guidelines– TENS

M h i l T i– Mechanical Traction

Tissue specific guidelines– Graded AROM

Neural gliding

Directional preference– Retraction/Protraction

– Flexion with contralateral rotation

Neck pain with Radiating PainManagement


E i t i / h i l Ergonomics on nerve tension/mechanical interface aggravating/easing positions

– Mechanical Thoracic spine manipulation

Mobilization of hypomobile segments above/below level (UCS/CTJ)

Strengthening of hypotonic cervical/scapular muscles in the region to address underlying instability

Support for Traction

CPR for traction in patients with neck pain

– Peripheralization with C4-7 mobility testingmobility testing

– Positive shoulder abduction test– Age ≥ 55– Positive ULTT A– Positive neck distraction test

4/5 criteria (LR+=23.1), Posttest probability 44% to 94.8% (Raney et al 2009)

CPR not validated!

Lack of Support for Traction

2008 Cochrane Review– No evidence that clearly

supports or refutes the use of

Systematic review: 10 trials

Population: Cervicobrachial syndromepp

either continuous or intermittent traction for individuals with chronic neck disorders (Graham et al 2008)

RTC comparing multimodal treatment for cervical radiculopathy with and without mechanical traction

– No difference between groups Young et al 2009

syndrome

Intervention: ICT or CCT compared to placebo

– No significant difference pain, disability short/long term (A)

– Potential change using sustained traction Salt et al 2011

Support for Directional Pref. ROM

Intervention: General exercise versus directional pref. ROM (McKenzie) versus control (low(McKenzie) versus control (low intensity US and education) x 8 weeks (Kjellman et al 2002)

– Up to 3w: McKenzie group for pain and disability

– 1 year: All groups for pain and disability

– Similar recurrence rates at 1 year

– C level evidence

Support for Thoracic Manipulation in Radiculopathy/Myelopathy

Traction, TSM, Exercise (ROM/DNF PRE)

B d t l JOSPT 2004– Browder et al, JOSPT 2004

– Cleland et al, JOSPT 2005

– Murphy et al, J Manipulative Physiol Ther 2006

– Waldrop, MA, JOSPT 2006

Significant reductions in pain and disability short term

Mostly B/C level evidence

6

Support for Cervical Manipulation in Degenerative Radiculopathy

Multimodal program consistingconsisting of STM, CSM, TSM, ROM, Traction, and DNF training

Forbush et al 2011

STIFFNESS-DOMINANT TREATMENT

Treatment Considerations

Primary treatment for patients in neck pain with mobility deficits category

Cl ifi ti f ti t ith diff ti t d i– Classification for patients with undifferentiated pain

– Treatment primarily focused on non-contractiletissue mobilization/stretching at the site of pain

May include later-stage treatment for tissues transitioning from pain-dominant state– Myofascial pain syndromes (MPS)/TTHA

– Neck pain with radiating pain

Progression of MPS/TTHA

Initiate higher intensity manual and self stretching once irritability hasonce irritability has subsided

Ischemic pressure– Sustained holds 30-60sec x 4


End-range stretching– Sustained holds 30-60sec x 4

Support for Ischemic Pressure

Cervicocogenic Headache and Dizziness Management

5x30sec ischemic 5x30sec ischemic compression to posterior nuchal muscle

Significant, immediate improvement in CROM, isometric strength, and sensory organization test scores (improved ankle strategy in conditions 4/5)

– Lin et al 2012

Progression of Neck pain with Radiating Pain

Disc– PA mobilization

Nerve Nerve– AP mobilization to increase IVF

diameter (Sizer et al 2001)

– Lateral glide with neural glide Significant improvement in pain

compared to ultrasound or articular mobilization techniques (Salt et al 2011)

Significant benefit and no increased risk of adverse events compared to controls (Nee et al 2012)

7

Primary Treatment for Joint Stiffness

Contributing Impairments– Physical

Spondylosis

Adhesion formation from healing

– MechanicalShort and strong musculature (Janda)

Underlying joint instability (lock)

Examples of Therapist-Administered Treatment

OA distraction

C1/2 rotation

Subaxial sideglides

APs or PAs

Subaxial Closing/opening mobilization

Soft tissue glides/ischemic pressure

Examples of Patient-Administered Treatment

Tennis/golf balls, Pivot therapy, Theracane

– Ischemic pressure andIschemic pressure and PA mobilization

Towel/hand-assisted mobilization

– Mobilization with movement

– Isolated ROM training

Support for Manual Therapy

Cochrane Review (33 trials)

Population: Mechanical neck pain with/without HA, acute to chronic

Intervention: 1-11 weeks– No significant short term effects (B)

Manipulation/mobilization alone

Manipulation/mobilization with physical agents

– Maintained long term effect (A) Manipulation/mobilization with exercise

– Gross et al, Spine, 2004

Manipulation versus Mobilization?

Cochrane Review (27 trials)

Population: Neck pain with/without HA/radic acutewith/without HA/radic, acute to chronic

Intervention– Manipulation and mobilization

equivocal at intermediate followup(B)

– Manipulation superior to control for pain at short term (C)

Gross et al 2010

The Risks of Cervical Spine Manipulation

Incidence of adverse events (AEs) reported between 1/50,000 to

Contraindications– Acute - fracture/dislocation/soft

tissue injury/myelopathybetween 1/50,000 to 1/5.85 million

44.8% of AEs potentially preventable by r/o contraindications

10.4% of AEs unpreventable

j y y p y

– Osteoporosis/recent surgery

– Ligamentous rupture/instability

– RA/AS/Connective tissue disease

– Vascular disease

– Tumor/Infection

– Anticoagulant therapy

– VA insufficiencies (5Ds)

– Nausea/Tinnitus/facial paresthesia

– No change or worse with manipsPuentedura et al 2012

8

CPRs for Mid-Cervical Manipulation

Tseng et al 2006– NDI < 11.5/50

– Bilateral involvement

Puentedura et al 2012– Symptoms < 38 days

– Positive expectation thatBilateral involvement

– No sedentary work >5 h/d

– Relief with neck motion

– No worsening with neck motion

– Spondylosis without radiculopathy

4/6 criteria (LR+=5.33), Posttest probability 60% to 89%

Positive expectation that manipulation will help

– Asymmetrical CROM rotation ≥ 10°

– Pain with PAs mid C-spine

¾ criteria (LR+=13.5), Posttest probability 39% to 90%

CPRs Not Validated!

CPR for Thoracic Spine Manipulation in Neck Pain

CPR for TSM in patients with neck pain (Cleland et al, PT, 2007)

– Symptom duration less than 30 daysNo symptoms distal to the shoulder– No symptoms distal to the shoulder

– No worsening with looking up– FABQ (PA) <12– Decreased T3-5 kyphosis– Cervical extension <30°

3/6 criteria (LR+=5.5), Posttest probability 54% to 86%; 4/6 (LR+=12), 93% probability

CPR for TSM Validation Study

140 patients with mechanical neck pain randomized to exercise (5v) or TSM (2v) plus exercise (3v)

– TSM CPR not validatedTSM CPR not validated

– Manipulation plus exercise group exhibited significantly greater benefits in disability at short and long term (1-4 wk, 6 mos) followups, pain in short term (1 wk) regardless of fitting CPR Cleland et al, PT 2010

TSM should be considered in all patients with mechanical neck pain (systematic review)

– Increased ROM, decreased pain, improved function Cross et al, JOSPT 2011

CPR for TSM Revisited

Patients fitting 4/6 TSM CPR

Received either TSM or Received either TSM or CSM

CSM group demonstrated more favorable response and fewer transient side effects

– Puentedura et al, JOSPT 2011

Superior Benefits of Cervical Spine Manipulation

Comparison of thrust and non-thrust upper cervical and upper

jospt perspectives for patients

Neck Paincervical and upper thoracic manipulation

– Significant improvements in ROM, pain, disability, and DNF function in thrustgroup Dunning et al, JOSPT

2012

Neck PainManipulation of Your Neck and Upper Back Leads to

Quicker Recovery

Equivocal Benefits of Cervical Spine Manipulation

1 week Kinesiotape v. 1 session CSM

– Similar reductions in

2x/w x 3 weeks, subacute-chronic, Nonthrust v. CSMSimilar reductions in

pain/disability and increased CROM Saavedra-Hernandez et

al 2012

1 time TSM v. CSM– Equivocal improvement in

CROM, pain pressure threshold, pain intensity Martinez-Segura 2012

Nonthrust v. CSM– Equivocal improvement

short and long term pain/disability Boyles et al 2010

2x/w x 2 weeks, acute, Nonthrust v. CSM

– No difference in number of days to achieve recovery Leaver et al 2010

9

The Bottom Line

No clear “best” approach

Apply clinical reasoning

Expert review of 736 typical patient cases– After consideration of patient

history, symptoms, radiology, and response to past treatment, CSM deemed appropriate in only 11.1% of cases

PRIMARY INSTABILITY IMPAIRMENT


Primary treatment for patients in neck pain with movement coordination impairments

Cl ifi ti f ti t ith diff ti t d i– Classification for patients with undifferentiated pain

– Treatment primarily focused on contractile tissue neuromuscular re-education/strengthening at the site of pain

Should be terminal classification for all tissues transitioning from pain-dominant state

Primary Treatment for Joint Instability

Contributing Impairments– Environmental/Physical

Poor posture, repetitive occupational trauma, acute trauma (Panjabi 1992)

Bifocal use

– Mechanical Treatment of flexion, extension, rotation

syndromes

Examples of Ergonomic Emphasis

Standing bra/purse adjustments

Sitting workstation positionFoot support– Foot support

– Seat support

– Lumbar support

– Arm support Passive correction of scapular

downward rotation improves pain, CROM, proprioception (Ha et al 2011)

– Neutral neck for sustained phone use

Sleeping pillow support– Neck support versus head support

Support for Pillow Selection

Comparison of polyester, foam, feather, and rubber pillows to a patient’s usualpillows to a patient s usual pillow in side-sleepers

Outcome measures were waking/temporal pain, sleep quality, pillow comfort

– Rubber pillow superior

– Foam/polyester equivocal

– Foam contour/regular equivocal

– Feather pillows inferiorGordon et al 2009

10

Steps to Exercise Application

1. Manual Therapy– Cervical PAs increase

deep neck flexor

2. Neuro re-ed– Begin with muscles

that have oppositedeep neck flexor activation and decrease superficial muscle activity Jesus-Moraleida et al

2011

– Thoracic manipulation reduced lower trap inhibition Cleland et al 2004

that have oppositefunction of syndrome Avoids aggravation

associated with loading into DSM

– Progress to working muscles actions intosyndrome Ensure activation of

weakest synergist

Initial Therapeutic Exercise Emphasis

Independent activation and tonic hold

DNF i t i ( t d )– DNF isometrics (ext. syndrome) Emphasis on good standing

posture with neck lengthening improves CCFT performance (Beer et al 2012)

– Cervical multifidus isometrics (flexion syndrome)

– Lower scapular isometrics (rotation syndrome)

Progression of Therapeutic Exercise Emphasis

Integrated tonic hold– Trunk flexion with head

in neutral (flexionin neutral (flexion syndrome)

– Head neutral with trunk lift (extension syndrome)

– Combined scapula and GHJ loading (rotation syndrome)

PRE/Function

Support for Primary Treatment

Deep Neck Flexor Strengthening– Local to global (Falla 2004)– Global versus local (O’Leary 2007)( y )

In chronic patients, each effective at increasing strength

Multifidus Strengthening– Significant changes in thickness up to 50% of maximum with

isometric head extension (Lee et al 2009)


Neck flexors and Scapula

Global strength– Global strength (1x15) versus endurance (3x20) Strength group:

Increased ROM/strength

Both showed reduced pain and disability at 1 and 3 years

– Ylinen et al 2003


Cochrane review (31 trials)

Population: Mechanical neck pain p pwith/without HA, acute to chronic

Intervention: 2-52 weeks– Stretching, strengthening, eye fixation

exercises supported (C)

– Combined manual therapy and exercise (A)– Kay et al, Cochrane Database Syst Rev, 2005

11

ACDF POST-OP MANAGEMENT(MAXEY AND MAGNUSSON 2013)

Specific Tissue Considerations

Contractile tissue incision– SCM, platysma, Anterior

scalene, Middle scalene, Longus colli

Non-contractile tissue resection

– ALL, PLL, Joint capsule, Synovium

Bone graft from iliac crest often used in disc space

Phase I-II Management (0-21 days)

Hospitalization 1-2 days

ContraindicationsNo CROM

Independent HEP– Lower quarter

stabilization– No CROM testing/intervention

– No UE MMT

Patient education– No lifting > ½ gallon of milk

– UE ROM ≤ 90degrees

– Wear cervical collar as directed

– Dysphagia in 28-51% of patients

stabilization

– UE ROM ≤ 90degrees

– Pec stretching (corner)

– Ergonomics

– Walking program

Phase IIIa Management (4-8 weeks post-op)

First appearance in outpatient PT (6w)

Treatment– CROM

U Contraindications– PRE above 90deg

elevation

– Mobilization to CT spine before radiographic evidence of callus formation

– Upper quarter stabilization Scapula

DNF

– UE PRE<90deg

– Neural gliding (not tensioning)

– Proprioception training

Phase IIIb-c Management (9-12+ weeks post-op)

No contraindications remaining

Treatment focus– Progression of PRE

– Restoration of full CROM and TROM C5-6 fusion will demonstrate 65-70deg max cervical

rotation post-op

– Incorporation of previously restricted functional overhead movements

Cervical Treatment Lab

I. Pain‐dominance treatment

a. Centralization (See patient handouts)

i. Retraction/Protraction

ii. Foraminal opening

iii. Traction

b. MET for meniscoid entrapment

i. Passive positioning to the barrier using

turban grip, with little finger hooked

around involved segment

ii. Opposite hand around inferior segment,

providing counter‐rotation

iii. Direct MET applied through turban grip arm

II. Stiffness‐dominance treatment

a. Post op considerations: Interventions to address ROM first allowed at 8 weeks post

ACDF, but may be delayed based on evidence of radiographic healing (Maxey and

Magnusson 2013)

b. Manual mobilization

i. OA distraction

1. Stand on side to be mobilized

2. Cradle head in contralateral rotation

3. Mobilizing hand on occiput, contact with palmar

MCP

4. Distract superior, in direction of forearm

5. Add contralateral sideglide to further achieve

end range

6. Apply HVLA thrust to comfort

ii. OA sideglide, C1/2 PA, C1/2 physiological rotation

1. Same as exam

2. Apply HVLA thrust to C1/2 physiological rotation

to comfort

iii. C2‐7 closing (downglide)

1. Contact involved articular pillar with 1st radial

MCP

2. Ipsilateral sidebend/contralateral rotation down

to the level

3. Sideglide contralateral at the level

4. Slight distraction with opposite hand

5. Mobilize into sidebend and sideglide, in the

direction of opposite axilla

6. HVLA thrust to comfort

MET

iv. C2‐7 opening (upglide)

1. Contact involved articular pillar with palmar

MCPs of index fingers (wrap the level)

2. Extend and sidebend (ipsilateral) down to the

level

3. Use component technique to take up slack

by squeezing down on the level with MCPs

4. Perform contralateral sideglide to take up

additional slack

5. Perform Contralateral rotation at the level, in the direction of the

opposite eye, to end range

6. HVLA thrust to comfort

v. C2‐7 AP mobilization

1. Slide pads of fingers one inch anterior/medial

from TP

2. Apply A to P graded mobilization

3. Simultaneously flex the neck to comfort

4. Avoid carotid artery with this technique

vi. C2‐7 sideglide with neural glide

1. Hand position for sideglide same as exam

2. Sideglide segment away from symptomatic

UE

3. Sustain sideglide as patient performs neural

glide on/off distally

vii. Subaxial PAs

1. Same as exam, central or unilateral

viii. Soft tissue mobilization

1. Suboccipital release

a. Achieve B MCP flexion and IP extension

b. Position digits 2‐5 at base of occiput

c. Allow for relaxation; supplement distraction

2. SCM, Scalene, Levator, Upper trap

a. Longitudinal or perpendicular tissue glides

b. Work from slack to stretch position

3. TrP Pressure Release

a. Increase pressure on TrP until barrier engaged

b. Maintain until release, then take up slack

Suboccipital release Scalene mobilization

c. Self mobilization (See patient handouts)

i. UCS Stretching

1. Towel for segmental mobilization

a. C1/2 rotation

b. OA flexion with C1 anterior glide

2. OA sidebending with hand block

ii. LCS Stretching

1. Hand collar with cervical closing

2. Upper trapezius, scalene, and levator stretching

iii. Neural gliding (shared exercises with upper thoracic dysfunction)

1. Put primary interface site on slack initially

2. Glide distally, progressing more proximally to spine as able

III. Weakness‐dominance treatment (See patient handouts)

a. Post op considerations: Multi‐plane cervical isometrics and UE PRE above 90degrees

allowed at weeks 9‐12 post ACDF (Maxey and Magnusson 2013)

b. Cervical extension (cervical flexion syndrome)

i. Tonic hold: Isometric cervical retraction

ii. Integrated tonic hold: Cervical retraction/rotation.

c. Thoracic flexion (cervical flexion syndrome)

i. Tonic hold: Isometric thoracic flexion

ii. Integrated tonic hold: trunk curl with thoracic flexion emphasis with/without

towel

d. Cervical flexion (cervical extension syndrome)

i. Tonic hold: Craniocervical flexion with stabilizer (not on patient handout, same

as exam)

ii. Tonic hold: Isometric craniocervical flexion

iii. Integrated tonic hold: Chin tuck with head lift with/without arm raises

e. Thoracic extension (cervical extension syndrome)

i. Tonic hold: Isometric thoracic extension

ii. Integrated tonic hold: scapular retraction, chest lift

f. Cervical rotation syndrome (see scapular exercises in thoracic lab)

Clinical Reasoning Lab Case 1 SUBJECTIVE Age: 63 Sex: Female Marital status: Married Occupation: Retired Recreational activities: Tennis, traveling, computer classes Chief Complaint: Low back pain and B LE pain History of Present Illness: 1. Onset: Initial 22 years ago with lifting. At the time of her original injury, she was diagnosed with a HNP by her orthopedic surgeon. Self-managed well with intermittent LBP until recent episode, beginning 4 months ago. No apparent trauma or predisposing factors. 2. Location: LBP, and new onset of B LE pain, which was not present before 4 months ago. Pain in LEs extended down into buttocks and posterior legs as far as calves and heels, but not into feet, seemingly following L5 or S1 dermatome. 3. Nature: Severe, sharp, shooting in LEs 4. Aggravating: Playing tennis, slow walking, prolonged standing greater than 1 hour, bending slightly forward to do dishes or vacuum, lifting heavy loads. Easing: sitting, lying down 5. Intensity: 0/10 best, 4/10 currently, 5/10 at worst 6. Associated symptoms: Patient denied numbness or tingling, bowel/bladder problems, or pain with cough/sneeze Functional limitations: Tennis limited to 15-20 minutes before significant onset of pain. Medical History: Unremarkable: denied weight loss/gain, history of trauma, HTN, TB, anemia, CA, heart problems, depression, thyroid problems, emphysema, hepatitis, asthma, kidney disease, or diabetes. One epileptic seizure many years ago and hospitalization for facial injuries after MVA at age 17, no residual impairments from either. Radiology: CT scan revealed central spinal canal stenosis with multiple level lumbar degenerative disc disease and a grade 1 spondylolisthesis at L5/S1. Prior treatment: ESI 4 months ago, resulting in 40-50% pain relief, but no change in location of symptoms. Anti-inflammatory med (nabumetone) decreased pain by another 20%. No previous PT. Physician said she might be a surgical candidate if PT not helpful.

Patient goal: Return to playing tennis and avoid lumbar surgery. OBJECTIVE Alignment: hyperlordosis with palpable step at L4/5, flattening of LS junction. Leg length symmetrical in prone. ROM: lumbar flexion full (fingertips to toes) and without pain provocation. Lumbar sidebending WNL, symmetrical, and painless, with normal pelvic coupling. Lumbar extension not pain provocative but significantly restricted at LS junction, with most extension occurring in upper lumbar spine. Active trunk rotation in sitting symmetrical and no pain provocation. Hip flexion, adduction, IR restricted R compared to L, with pinching in R anterior hip and groin. Active hip extension in prone limited by over 50%, less than 10deg in range B, with decreased tone noted in gluteus maximus, especially on the R. Flexibility: Tight hip flexors R compared to L, especially iliopsoas. Passive SLR 80deg B. Neurological: No sensory deficits and no motor weakness in LEs. Reflexes not tested. Palpation: ILA position with patient fully flexed in sitting revealed L posterior/inferior ILA. Lumbar TPs with patient fully flexed in sitting revealed no asymmetry L2-L5, R rotation of L1. Pubic symphysis inferior pube on R, with tenderness of R inguinal ligament. Marked increase in tone of R lower abdominal quadrant for iliacus and psoas. Significant tightness and tenderness noted on palpation of R long dorsal SI ligament. Palpation in prone on elbows revealed R TP of L5 posterior, L TP of L4 posterior. Accessory mobility testing: AP translation of innominates revealed restriction on R compared to L. AP glide of R hip limited compared to L. Loss of anterior nutation at R sacral base. Unilateral Pas on R TPs of L1-S1 produced significant local pain at L4 and S1. Hypomobility L T11-12 for closing. Special Testing: positive standing/seated flexion test for SIJ R. Positive one legged stork test R. Negative SLR B for symptom provocation. Active heel slide revealed significant imbalance in muscle control on R versus L.

Clinical Reasoning Lab Case 2 SUBJECTIVE Age: 14 Sex: Female Marital status: Single Occupation: Student Recreational activities: Cheerleading/tumbling Chief Complaint: Lack of improvement from sprained ankle History of Present Illness: 1. Onset: Initial 3-4 weeks ago while participating in cheerleading practice. MOI was inversion sprain from landing on another team member’s foot during a lift maneuver. She rested for a few moments, and although the ankle was tender, she was able to continue the work-out session. Three days later she returned to the gym for a follow-up work out and reinjured the same ankle following a jumping maneuver. She landed on the outside aspect of the foot and described hearing a pop, immediately experienced severe pain and was unable to place any weight on the right foot. She was referred to an athletic trainer, who advised she apply ice, elevation, and a compression wrap, and exercise the foot as much as possible. He encouraged her to walk with axillary crutches WBAT. After 2 days of no improvement, she saw an orthopedic surgeon. He ordered her to use the crutches NWB and perform ankle DF/PF to pain tolerance for 2 weeks. After 2 weeks of no improvement, he ordered PT. 2. Location: inferior to lateral malleolus, anterolateral aspect of ankle. 3. Nature: throbbing (lateral malleolus), tingling over anterolateral aspect of ankle 4. Aggravating: any weight bearing or pressure. Throbbing and tingling increased with dependent position for 1-2mins. 5. Intensity: 0/10 rest, very intense with any weight bearing or pressure 6. Associated symptoms: discoloration to dark purple and spotted when in gravity dependent position for even a few seconds. Toes and forefoot would begin to shake sometimes, lasting only a few seconds, occurring when she tried to move or position her toes or ankle. R toes and ankle cooler than L. Patient denies numbness. Limitations: NWB R LE, reluctant to place foot on floor. Unable to wear shoe because of slight ankle and foot swelling, and because of increased sensitivity, primarily over all her toes and the anterolateral aspect of the foot and ankle. Only able to tolerate elastic bandage and an oversized fleece stocking for ankle support and protection. . Medical History:

Unremarkable for any prior history of ankle injuries or any history of spinal complaints. No symptoms/problems elsewhere and her general health was unremarkable. Radiology: Posteroanterior, lateral, and ankle mortise views were negative for fracture at first orthopedic visit, and 2 weeks later. Prior treatment: trainer and orthopedic surgery recommendations as described. Anti-inflammatory med (naproxen 375mg, 2x/d) taken sporadically. Unsure whether it had any benefit. Extra moisturizing lotion applied to forefoot daily to overcome dryness. Patient goal: Return to cheerleading squad ASAP and participate in cheerleading competition in 2 weeks. OBJECTIVE Observation: mottled foot in gravity-dependent, blanched when elevated for 20-30secs. ROM: All active movement of toes, subtalar and ankle joints guarded and incomplete as a result of pain. Slight quivering of the toes noted during movement. Active assisted DF L ankle 8deg, 2deg R. PF limited R to 25deg, compared to 50deg L. Active and passive PF with subtalar supination produced discomfort in the lateral ankle region. Other active motions not quantified. End feel of passive calcaneal inversion soft and painful before tension perceived. End feel of calcaneal eversion normal. Normal end feel and no pain with midtarsal oblique and longitudinal axes motion. Hip and knee motion unremarkable. Thoracic rotation limited to R and slightly uncomfortable at end range locally compared to L. Strength: MMT deferred because of discomfort. Neurological: decreased sensation to touch in superficial peroneal nerve distribution. Palpation: cooler R foot than L, with calf measuring 2deg F cooler than L. Plantar and dorsal aspects of R foot dryer than L. Capillary filling time of distal right great toe prolonged compared with L. Posterior tibial and dorsalis pedis pulses present and equal B. Accessory mobility testing: Not tested Special Testing: R SLR without ankle/foot positioning produced discomfort and tingling in R lateral ankle at 50deg. Peroneal nerve sensitization with SLR extended discomfort and tingling into lateral forefoot and toes. No increase in tingling when tibial or sural nerves sensitized. SLR L 95-100deg with stretching in thigh only.

Clinical Reasoning Lab Case 3 SUBJECTIVE Age: 14 Sex: Male Marital status: Single Occupation: Student Recreational activities: Competitive Karate, former champion Chief Complaint: Severe B groin pain History of Present Illness: 1. Onset: 18month history of severe B groin pain. Occasional pain noted in R groin before severe onset, but pain was not present during activity and did not interfere with activities such as walking, running, or sports. Patient had tragedy involving another sibling about 20months ago, at which time he had to halt participation in all sports for about a month. As patient resumed participation in karate, previous pain returned, more intense, and began on L. 2. Location: R>L groin 3. Nature: intense ache 4. Aggravating: pain with walking for 15mins, requiring him to walk slowly. Pain with attempting to lift L or R thigh (knee to chest) greater than 100deg. Pain with squatting. Pain after 20mins of sustained standing. Occasional pain with rolling or standing from sitting. Easing: sitting or when in the recumbent position. 5. Intensity: 2/10 at best, 8-9/10 at worst. 30-40mins to subside once severe pain hits. 6. Associated symptoms: None reported Medical History: Unremarkable. Thorough workup for systemic, visceral, genitourinary disease explaining current complaints was negative. Radiology: Negative for hip or pelvic lesions. Prior treatment: “Take it easy, avoid karate” recommended by pediatric orthopedic surgeon, adhered to for over a year, condition not improving. Patient goal: Return to karate OBJECTIVE Alignment: thoracic and lumbar spinal curves normal. Iliac crest level without pelvic rotation or tilt. Patient stood in B hip abduction and slight ER.

ROM: Lumbar flexion primarily in lumbar spine with hip flexion limited to 60deg, painfree. Sidebending and rotation with pelvis stabilized were painfree and symmetrical. Lumbar extension not tested. Passive hip flexion limited B to 90deg by pain in the groin. Passive ER and posterior femur loading increased range by 10deg before pain. Active hip flexion limited by groin pain at 80deg. Passive hip ER 75deg B. Passive hip IR B 10deg. Active hip extension full range, hamstring dominant, anteromedial femoral glide. Seated knee extension accompanied by femoral IR was -30deg B, -35deg when hip IR prevented. Flexibility: Thomas test: R hip 25deg from full extension, painless. Extension full when hip allowed to abduct. L hip 20deg from full extension, painless, in neutral, full extension in abducted position. SLR limited to 50deg B with anteromedial femoral motion. FABER WNL B with groin pain at end range. Ober 10deg from neutral abd B. Strength: IO and rectus abdominus 4/5. EO and rectus abdominus 4/5. Posterior gluteus medius 3/5 R, 3+ L. Hip in TFL test position, 5/5 B. Gluteus maximus B 4-/5. Iliopsoas 3+/5 B. Hip ER 4-/5 B. Accessory mobility testing: Not tested Special Testing: SLS resulted in R>L hip medial rotation. Iliopsoas isometric testing painfree, difficult to maintain.

Clinical Reasoning Lab Case 4 SUBJECTIVE Age: 48 Sex: Male Marital status: Unknown Occupation: Self-employed graphic designer Recreational activities: None reported Chief Complaint: intermittent L sided mid to low lumbar deep aching, when severe would spread across to R side History of Present Illness: 1. Onset: 10 weeks ago, when patient tripped (unsure why, thinks he stumbled on a paving stone) in the street and fell forward with hands in pockets, more towards the R. He was unable to break his fall, but he did not lose consciousness. At the time patient felt unharmed, but symptoms began over next 3 days. 2. Location: L sided mid to low lumbar deep aching, when severe would spread across to R side. Pain would radiate B towards outer hips, over the greater trochanter. Pain also radiated posteriorly and down through the L buttock, posterior thigh and calf, but not into the foot. No pain noted in R LE. Band of L thoracic pain intermittently, from lower L scapula to L thoracolumbar level. Intermittent ache over dorsum of B hands. Pain in superior B scapulae. Patient denied neck or head pain, throat, chest, or abdominal symptoms. 3. Nature: intermittent ache in lumbar spine. Intermittent deep ache also in L LE. Posterolateral L calf was extra sensitive. L thoracic pain described as “electric sensitivity. Intermittent ache over B hands and superior scapulae. 4. Timing: Symptoms initially the same one week after fall, now improved slightly. 5. Aggravating: Standing and walking, especially noted with distance greater than 100m. Working seated on the edge of his stool also increased back and leg pain. Easing: Lying supine 6. Associated symptoms: slight numbness in 3rd and 4th toes of L foot. Weakness in R LE causing him to drag the leg as he walked, with his foot dropping towards the end of the day. Increasing weakness R hand, making it difficult to hold a pencil. Intermittent swelling over dorsum of L hand. No pain with cough/sneeze. Micturition normal though slow.

Functional limitations: difficulty walking, carried a stick when his back was bad. Medical History: HTN controlled with medication. Gout controlled with allopurinol. No diabetes, weight steady, overweight but not obese. Radiology: No radiographs taken. Prior treatment: Occasional ibuprofen, little effect. Osteopathic manipulation to neck and shoulders—eased shoulder pains, but not lower quarter symptoms. Patient goal: Decrease pain. OBJECTIVE ROM: Lumbar flexion fingers to tibial tuberosities, limited by increased LBP. Passive neck flexion at end range lumbar flexion increased L buttocks pain. Trunk extension limited by stiffness at 20deg with central LBP. Sidebending L restricted but painless; sidebending R restricted and painful R low back. Gait: Wide BOS, unsteady without stick, decreased R knee flexion during swing with limb circumduction. Decreased R foot DF during lift off and swing phases. Gait suggestive of extensor spasm. Balance L LE steady, wobbly R LE. Neurological: B calf muscle weakness in standing. R ankle DF and evertors considerably weak. Decreased sensation to light touch and pinprick throughout L LE. DTRs hyper-reflexic B; ankle clonus present R. Positive Babinski B. Special Testing: Passive neck flexion in supine to 70deg symptom free. SLR 80deg L painfree without sensitizer, reproduction of familiar pain with DF. R SLR limited to 60deg with hard resistance.

Cervicothoracic Case History: 45 year-old female. Accountant. No regular exercise. Very sedentary. Mildly overweight. Chief complaint is pain. Pain location: Right cervical spine (from about C4) that runs down the right lateral shawl region. Pain onset: Insidious over the past 4 weeks. Pain nature: Ache, worsening over the past 4 weeks Aggravating: Extended computer use or driving, looking up, turning right, right S/L at night. Easing factors: Warm shower on neck and looking downward Timing: Pain is worse in the afternoon at work after sustained postures for computer use; best in the morning after her shower. Intensity: At best the pain is 3/10, at worst 8/10. Currently a 5/10 Associated symptoms: No numbness/tingling, weakness, dizziness, or headache. PMH: Significant for Osteopenia. R shoulder impingement diagnosis 1 year ago. R shoulder pain resolved with steroid injection; no PT intervention. No previous complaints of neck pain. Imaging: Xrays have been taken and are remarkable for degenerative changes at C4/5. Prior treatment: No medical care, besides visit to PCP, for this episode Medications: No meds. Extra information that may help describe the situation: Pt is an accountant. As tax season is upon us, she is spending long hours at work on her computer. She relays her posture to you as one in which she must look up slightly to see her computer screen. Her chair does not have armrests and her keyboard is sitting atop her desk. She sometimes spends four hours at the computer without getting up. She sleeps on one pillow and prefers her right side, which is painful at present. She is a single mother of two living in a single story home. She does report stress at home and work, and feels that pain is worse when stress is highest.

STOP & Plan for Exam List your pathology hypotheses and procedures for testing (Contractile, non-contractile): List your contributing factor hypotheses and procedures for testing where appropriate (Physical, Behavioral, Emotional, Environmental, Biomechanical): List your precautions/contraindications:

Exam: Alignment: R scapula adducted and downwardly rotated compared to left. Right shoulder depressed when viewed anteriorly. Moderate forward head and anteriorly tilted scapulae bilateral. Skin crease at C4/5. R rib elevated. Increased CT kyphosis. Decreased mid thoracic kyphosis. Thoracic TPs deep on the R from T3-5. ROM: Cervical spine: Flex: Full ROM with pulling at CT junction and upper thoracic spine at end ROM Ext: ROM limited to 50% with pain at right mid cervical spine and shawl. Crease deepens at C4/5 with movement. Sidebending: Left SB pulls right lateral cervical muscles with ROM limited 25%. Right SB

increased pain right cervical spine to shawl, full ROM. Rotation: ROM limited by 25% to left with end ROM pulling R shawl; ROM limited by 50% to right with pain limitation right cervical to shawl. CT differentiation test resulted in decreased neck and shawl pain when thoracic R rotation applied. Pain eliminated when C spine returned to neutral and R thoracic rotation maintained. Passive overpressure to neck ROM revealed firm end feel and pain with significant motion restriction into R closing quadrant, primarily at C2/3. Repeated movements were not tested. Shoulder screen revealed symmetrical B shoulder elevation limited 15deg without pain. Patient reported pulling into R cervical spine with elevation of R shoulder. C2 SP moved ipsilateral with R shoulder elevation. Flexibility testing: Pec minor 2” R, 1.5” L. Levator length limited R compared to L. Strength testing: Neck flexor endurance test 12secs. Serratus 3+ R, 4 L. Low traps 3+ B. Neurological testing: Not performed Palpation: concordant sign tenderness to palpation and trigger point at R levator. Concordant sign tenderness with slight referral to R shawl at R C4/5 articular pillar Segmental mobility testing: C1/2 rotation symmetrical to 40deg. PA to C4 has empty end feel. PA to C2/3 and C7/T1 stiff, especially on R. PA to T3-5 very stiff centrally. First rib depression R is stiff compared to L. Sidegliding revealed decreased left sideglide, more limited in extension, at C2/3. Special testing: Positive CRLF test when head rotated L and flexed to R. Negative dural tension test cervical. Negative traction testing. Cervical pain with positioning for Spurling’s B, but no increased pain with compression.

ASSESS & TREAT List your pathology hypothesis (Contractile, non-contractile): List your biomechanical and other contributing factor hypotheses: State your prognosis: State your management plan within the context of pain-dominant versus impairment-dominant treatment and the directional susceptibility to movement for the cervical spine:

1

Thoracic Spine Applied Anatomy



Objectives

Discuss concepts relevant to thoracic pain of red flag origin

Discuss concepts relevant to pathophysiology Discuss concepts relevant to pathophysiology and differential diagnosis for neuropathic pain originating from the thorax

Discuss concepts relevant to pathophysiology and differential diagnosis for disc and joint disorders of the thorax

Discuss concepts relevant to pathophysiology and differential diagnosis for mobility of the thorax

RED FLAGS

Vertebral Compression Fracture

Female Age > 70 Significant trauma

Female

Age > 52

No leg pain Significant trauma Prolonged corticosteroid

use ¾ = + LR of 218

– Henschke et al, Arthritis Rheum 2009

No leg pain

BMI ≤ 22

No regular exercise

4/5 = + LR of 9.6

2/5= - LR of 0.16– Roman et al, JMMT 2010

Spinal Cancer

Age > 50

Previous hx cancer

Failure to improve in 1 mo of therapy

Unexplained weight loss– Sens = 1.0; Spec =

.60– Deyo and Jarvk, Ann Intern

Med 2002

NERVE

2

Pathophysiology of Neural Structures

Radiculopathy rare due to high exit point of roots in IVF

Myelopathy possible due to small cord and canal T4-T9

Tension on sensory branches and sympathetic ganglion, most commonly T2 to T4

– Sizer et al, Pain Practice, 2001

Pathophysiology of T4 Syndrome

Intercostobrachial nerves contribute to

– Posterior brachial cutaneous branch of radial nerve

– Medial cutaneous nerve of the arm and forearm

T2 sympathetic ganglion (Fraser, J Orthop Med, 1993)

– Extremity swelling– Weakness of grip– Difficulty breathing

Pathophysiology of Sympathetic/Somatic Pain

Extensive branching between systems

Close proximity to heads of ribs Close proximity to heads of ribs, ventral aspect of vertebral column (Nathan, Spine, 1987)

Sympathetic ganglion– Head and neck C8-T5

– UE T2-T10

– LE T10-L2

Evidence of T10 Syndrome?

52-year old female with low back and B LE symptoms

Unremarkable exam except– T10-12 stiffness

– Positive sympathetic slump Longsitting slump with

contralateral thoracic sidebend/rotation and Grade 4 AP pressure on ribs corresponding to sympathetic ganglia referral distribution

– Cleland and McRae 2002

Geerse 2012

Differential Diagnosis of Neural Structures

Radiculopathy– Spinal levels in relation to

Sensory/motor levels 2 segments above for T1-6 3 segments above for T7-

10

– Abdominal weakness T6-12

Myelopathy– Mild paraparesis of LEs– Positive Babinski– Wide-based gait– Occasional sensory

disturbances

LOCAL THORACIC PAIN

3

Pathophysiology of Local Thoracic Pain

Disc disorders– Disc Protrusion

Disc Prolapse– Disc Prolapse Joint disorders

– Zygapophyseal joint– Ribs

Costotransverse joint Costovertebral joint Costochondral joint

Pathophysiology of Disc Disorders

Protrusion– More common than once

believed– Commonly seen in mid-

thoracic segments– 11% of documented

lesions on MRI were symptomatic on discography (Errico et al 1997)

Pathophysiology of Disc Disorders

Prolapse– Tend to occur in mid

to lower thoracicto lower thoracic More flexion/extension

available Increased load bearing

(Edmondston and Singer, Manual Therapy, 1997)

– 33% of body weight at T8

– 47% of body weight at T12

Pathophysiology of Joint Disorders

Zygapophyseal joint– T1-4

Morphologically similar to i l icervical spine

Moves with cervical motion

– T5-8 UE elevation creates

movement down to T5/6

– T9-12 Morphologically similar to

lumbar spine LE motion creates

movement up to T8


Zygapophyseal arthropathy often associated with secondary disc disorder

Most common sites– C7-T1– T3-5– T11-L1– Sizer et al, Pain Practice,

2001– Shore, British J Surg, 1985


Ribs– 1-4

Often seen in MVA/whiplashp

– 2-3 Costochondritis Women>men, Left>right

– 3-5 Disc narrowing leads to CV joint

arthrosis

– 8-10 Slipped rib tip Hyperkyphotic posture or direct

trauma

4

Differential Diagnosis of Disc Disorders

Disc (Sizer et al 2001)– Uniplanar rotation or

flexion provocativeflexion provocative– Breathing provocative– Dural irritation

PLL/posterior annulus attached to dural sac

Production of positive dural signs

– Neck flexion at end range thoracic rotation

– Thoracic slump

Differential Diagnosis of Joint Disorders

Zygapophyseal Joint– 3-D motion testing

most provocative, butmost provocative, but coupling is variable

Rib Joints– Uniplanar

sidebending most provocative

– Breathing provocative

MOBILITY

Pathophysiology of Mobility

Posture and ROM– Non-contractile

determinants Vertebral body/disc

shape

Tension in associated ligaments

– Contractile determinants Deep one joint muscles

and thoracic long extensors

Differential Diagnosis Mobility

Age predictive of impairment– Old likely related to anatomical changes

Postural correction not likely except through cervical and lumbar spine

– Young likely related to postural muscle weakness/stiffnessPoor correlation between thoracic kyphosis angle

and thoracic extension ROM (Edmondston et al 2011)

Thoracic postural correction possible Flexion-rotation syndrome most common

– Sahrmann 2011


Rotation syndrome– Pain/asymmetry with

rotation/sidebendrotation/sidebend– Pain with unilateral

shoulder flexion– SB/rotation postural

deviation around area of pain (possibly scoliosis)

– Weak intrinsic thoracic paraspinals, lower scapula, and obliques

– Stiff ribs, lats

5


Flexion syndrome– Young: worse pain with

prolonged flexed sitting– Older: Pain with reversal of

flexion/walking/standing– Pain/Increased thoracic flexion– Limited thoracic extension– Thoracic kyphosis, swayback– Weak intrinsic thoracic

paraspinals, scapula retractors, TRA, and external obliques

– Stiff lumbar paraspinals, rectus abdominus, internal obliques


Extension syndrome– Pain with extension or return

from flexionfrom flexion– Limited thoracic flexion,

tilted/winged scapulae– Military posture– Weak abdominals (rectus

and IO) and serratus– Stiff thoracic extensors and

scapular adductors

1

Thoracic Spine Differential Diagnosis



Objectives

Describe the relevant findings from the history and examination consistent with a contractile tissue source of symptoms

Describe the relevant findings from the history and examination consistent with a non-contractile tissue source of symptoms

Objectives

Describe the relevant findings from the history and examination consistent with stiffness as a primary impairment to movement

Describe the relevant findings from the history and examination consistent with instability/weakness as a primary impairment to movement

CONTRACTILE TISSUE PATHOLOGY


Demographics– Age 6 to 40, Females (3:1)

Nature– Deep aching, occasionally lancinating

Aggravating– Cold– Psychological stressors– Anxiety– Sustained postures

Associated symptoms– Paresthesias (nondermatomal)



2






Test Response

Alignment P. min: Ant tilted scapula; Lat and P. maj: IRGHJ; Serr post: Leg length discrepancyGHJ; Serr post: Leg length discrepancy

ROM/Flexibility Restrictions noted primarily in GHJ and STflexibility. Patient may demonstrate decreased rib expansion with Serr ant TrP

Muscle Provocation Testing Painful, possibly weak (no atrophy)

Palpation 1) Focal tenderness with concordant sign reproduction (about 3kg of pressure)

2) Twitch response3) Taut band4) Often referred pain (non dermatomal) on

continued (~5sec) pressure

NON-CONTRACTILE TISSUE PATHOLOGY

Nerve

T4 Syndrome

Thoracic Outlet Syndrome– Scalenes

– First rib/ Costoclavicular space

– Pec minor

T4 Subjective Exam Findings

Demographics– Females 4:1, Age 30-50

Location

Timing– Night or early morning

pain/paresthesia Location– Upper A/P thoracic spine

– Unilateral to bilateral UEs

– Craniofacial

p p

Associated Symptoms– Glove distribution of

paresthesia into hands

– Swelling of extremity

– Weakness of grip

– Difficulty breathing

3

TOS Subjective Exam Findings

Demographics (neurogenic TOS)– Females 3-4:1

Onset Onset– History of neck trauma or work repetitive stress

Aggravating Factors– Arms in elevated position**

– Sustained postures

Timing– Night or early morning pain/paresthesia (release phenomenon)

Associated Symptoms– Paresthesias C8/T1**


Test Response

ROM UE: Active and Passive ROM equal and painful in same direction; TOS: Cervical spine motion non-same direction; TOS: Cervical spine motion nonprovocative except when scalene on stretch

Accessory mobility T4: Concordant sign with T4 PA

Special Testing TOS: Positive ROOS**; T4/TOS: Positive ULTT; TOS: Positive Adson’s

Neurological exam TOS: Sensation, strength may be altered at C8/T1T4: Sensation/Pain in non-dermatomal pattern

Palpation TOS: Supraclavicular tenderness over brachial plexus**

Diagnostic Accuracy of Special Testing

TOS provocation testing– ROOS, Supraclavicular

pressure Costoclavicularpressure, Costoclavicular maneuver, Adson’s, Wright’s, Cyriax release, ULTT

– ROOS Most specific TOS test

LR+=1.2-5.2

– Adson’s Most sensitive TOS test

LR-=.28 Hooper et al 2010

Joint/Disc

Thoracic Spine– Difficult differential diagnosis

– Rotation testing is keyRotation testing is key

– Combined or coupled motions: Joint

– Uniplanar motions: Disc

Thoracic Ribs– Sidebending testing is key

– Uniplanar motions: CV, CC, or CT joints

Subjective Exam Findings--Disc

Location– Midline mid thoracic

– Paravertebral T9 or lower

Aggravating– Prolonged flexion/stooping

– Coughing, sneezing, deepParavertebral T9 or lower

– Band like lower chest wall pain

Onset (49%)– Result of axial trauma

– Lifting with twisting Linscott and Heyborne

2007

Nature– Aching

Coughing, sneezing, deep breathing

– Lifting

Easing– Recumbency

Associated symptoms – Paresthesias, weakness

Subjective Exam Findings--Joint

Location– Typically unilateral, not midline

O i l di i i h ll (CV/CT)– Occasional radiation to anterior chest wall (CV/CT)

– 2nd/3rd ribs anterior (CC)

Aggravating factors (Ribs)– Deep breathing

– Coughing/sneezing

4

Subjective Exam Findings- Costotransverse Joint Location

Young et al, BMC Musc Disorders, 2008

Subjective Exam Findings- Zygapophyseal Joint Location

Dreyfuss et al 1994; Fukui et al 1997


Test Response

ROM Active and Passive ROM painful in same direction; CV/CT: Ipsilateral sidebendingdirection; CV/CT: Ipsilateral sidebending, Flexion; 1st rib: Cervical rotation ipsilateral, SB contralateral; Disc: Flexion, Rotation; ZJ: Flexion, Rotation, Sidebending

Special Testing Disc: Positive dural tension thoracic slump; Rib: Pain with thorax compression

Palpation CV/CT: Tender CT joint and rib angle

PRIMARY STIFFNESS IMPAIRMENT


Same underlying ROM characteristics as cervical hypomobility

Other unique impairments Other unique impairments– Rib positional faults

– Positive CRLF (Lindgren) test for first rib stiffness

Interrater reliability K = 1

Correlation with radiologic findings K = .84

– (Lindgren et al 1989)

Thoracic ROM Diagram

5

Patterns of Motion Loss

Z Joints– T1-4 follows

opening/closing patterns p g g pof Cervical spine

– Mid thoracic patterns inconsistent due to coupling characteristics

Ribs (CV)– Inhalation restriction

– Exhalation restriction


Physiological– Mobility K = .27-.65 for T5-7

– Brismee et al, J Manip PT, , p ,2006

Accessory– Mobility K = .2-.4 for Thoracic

– Haas et al, Chiropr Tech, 1995

– Pain K = .12 for T7-10– Horneij et al, J Rehabil

Med, 2002

Reliability of Palpation Testing

Palpation for position– SPs primarily affected

by pull of largeby pull of large, powerful trunk muscles

– Thoracic spine common site for normal variations in skeletal anatomy

Rib Mobility Assessment

Ankylosing Spondylitis– Chest expansion

Circumferential measurement at axilla, 4th

intercostal space, nipple line, 10th rib taken at maximal exhalation and inhalation

Less than 2.5cm difference is 94% specific for AS (Rigby and Wood 1993)


Ventral hyperactive musculature

– Pec minorPec minor

– Biceps

Dorsal hyperactive musculature

– Middle and upper trapezius

– Levator scapulae

Flexibility Testing

Pec minor– Position: Supine

hooklying, low back flat; y gArms at side, elbows flexed, hands on abdomen

– Normal: Posterior acromium ≤ one inch from table

Short head of biceps– Increased stiffness with

elbow extended

6

Flexibility Testing

Latissimus dorsi– Position: Subject

raises arm in flexionraises arm in flexion overhead

– Normal: 180deg of flexion with back flat and arms close to head

– Considerations: Kyphosis, tight pec minor

PRIMARY WEAKNESS IMPAIRMENT


Same underlying characteristics as cervical instability

Other factors to consider– Systemic hypermobility

– Post MVA

– Post thoracotomy or laminectomy


Same underlying ROM characteristics as cervical instability

Other possible impairments– Excessive/Reduced kyphosis

– Rotational positional fault/scoliosis

– Weakness of longissimus (erector spinae)

– Atrophy of multifidus

– Weakness of abdominals

Strength Testing

Multifidus active with contralateral rotation

Longissimus active with Longissimus active with ipsilateral rotation

Both active with ipsilateral sidebending/extension

– Lee et al, J Electromyography and Kinesiology, 2009

Strength Testing

Thoracic extensors

Grading– 5 = hands behind

head, clears ribs

– 4 = hands at side, clears ribs

– 3 = hands at side, clears sternum

– 2 = hands at side, clears head

7

Strength Testing

Rectus and obliques

Grading– 5 = hands behind head,

clears scapulae

– 4 = hands across chest, clears scapulae

– 3 = hands at side, clears scapulae

– 2 = hands at side, partial lift-off

Thoracic Examination Lab

I. Palpation/observation for position

a. Spine: Scoliosis, Rib hump; Kyphosis

b. First Rib: Symmetry of position

c. 2‐10 Ribs (Flex and rotate trunk away to expose ribs)

i. Stuck in inspiration

1. Palpate increased spacing between ribs (suspect superior rib stuck)

2. Confirmation: space remains open when patient exhales

ii. Stuck in expiration

1. Palpate decreased spacing between ribs (suspect superior rib stuck)

2. Confirmation: space remains closed when patient inhales

II. ROM testing

a. Cardinal plane movements (AROM) with Overpressure (PROM) i. CT testing

1. Cervical rotation to pain 2. T1‐4 ipsilateral manual rotation 3. Increased ROM or decreased pain confirms CT junction stiffness

ii. Thoracic testing (25, 50, 75% limited)

First rib symmetry Rib 2‐10 symmetry

CT junction testing Upper thoracic SB with overpress. Lower Thor. SB with overpress.

Flexion with overpress. Extension with overpress. Rotation with overpress.

b. Quadrant tests (3‐D movement) i. Same combinations as cervical spine

c. Repeated movements i. Press up with emphasis on thoracic extension ROM

and anterior spinal translation ii. Quadruped rocking back with emphasis on thoracic

flexion ROM and posterior spinal translation

d. Shoulder screen i. ROM and effect on concordant sign

e. Chest expansion (assess difference between max inhalation/exhalation at 4 points. Normal difference is 1‐3in)

i. Axilla ii. Fourth intercostal space iii. Nipple line iv. 10th rib

III. Flexibility testing

a. Pectoralis minor

i. Posterior acromium ≤ one inch from table

b. Latissimus

i. 180deg of flexion with back flat and arms close to head

IV. Strength testing

a. Back extensors

i. 5 = hands behind head, clears ribs

ii. 4 = hands at side, clears ribs

iii. 3 = hands at side, clears sternum

iv. 2 = hands at side, clears head

Thoracic Closing Quadrant

Pec minor flex. Latissimus flex.

Prone press up Quadruped flexion Chest expansion test

b. Rectus and obliques

i. 5 = hands behind head, clears scapulae

ii. 4 = hands across chest, clears scapulae

iii. 3 = hands at side, clears scapulae

iv. 2 = hands at side, partial lift‐off

c. Serratus

i. Test of scapular upward rotation hold capacity at 120deg elevation. Avoid

compensatory anterior scapular tilt or elevation.

d. Trapezius

i. Lower: resisted scap adduction/depression with UE at 120 (avoid compensatory

scapular elevation)

ii. Middle: resisted scap adduction with UE at 90 (avoid compensatory scapular

elevation/depression)

iii. Upper: resisted shrug with UEs overhead (test at full scapular elevation)

V. Palpation for condition

a. Myofascial pain syndrome

i. Same considerations as cervical spine

ii. Bordering the scapula

1. Assess ease of lifting medial scapula

border away from trunk

2. Assess ease of sliding under lateral

scapular border

b. Muscle atrophy Multifidus

i. Assess for asymmetry in muscle bulk, just adjacent

to spinous process

VI. Joint mobility testing

a. T1‐12 PA

i. Contact SP or TP with hypothenar eminence using “dummy hand” technique

ii. Glide P to A in plane of facet

iii. Assess size of neutral zone and resistance at end range

Serratus MMT Low trap MMT Mid trap MMT Upper trap MMT

b. 1‐2 Rib depression

i. 1st: Sidebend head ipsilateral to slacken scalenes. Contact first rib with radial

first MCP. Keep palm of mobilizing hand facing anterior. Glide medial/inferior.

ii. 2nd: Located 1 thumbs‐width down 45deg from first rib. Mobilize inferior/lateral

using hypothenar emimence and “dummy hand”

c. 3‐10 Ribs PA spring assessment CT or CC

i. Stand opposite side to spring

ii. Stabilize same side TP of rib level

iii. Contact rib angle with lateral border of hand, running hand in direction of rib.

Keep hand flat (diffuse contact).

iv. Take up soft tissue slack (screw mechanism)

v. Spring anterior/lateral

d. 3‐10 Ribs Superior/Inferior assessment CV

i. Patient sidelying with test side up

ii. Using two hand grip, grasp rib to be tested between

thumb and forefinger

iii. Push up and over to assess s superior/outflare glide

iv. Push down and in to assess inferior/inflare glide

VII. Special testing

a. CRLF (Test of 1st rib elevation)

i. Rotate head contralateral to rib being tested and

maximally side‐flex neck

ii. Look for asymmetry of flexion between sides

b. ROOS

i. Arms in 90/90 position, rapidly open and close hands

ii. Positive: Arms drop, ischemic pain, weakness, N/T of

hand before 3mins

c. Adson’s

i. Rotate head ipsilateral, abduct, extend, and ER shoulder, hold breath

ii. Positive: Pulse obliteration and concordant symptoms within 10secs

d. Thoracic dural tension

i. Longsitting with one leg flexed

Thoracic PA 1st rib glide 2nd rib glide Rib spring 3‐10

ii. Flex neck, slump, and DF ankle. Look for concordant sign

iii. Positive: maintain slump and symptoms change with alteration of neck flexion

or DF

e. Thorax compression

i. Concordant sign reproduction with rib compression—specific for rib dysf.

f. Sympathetic Slump

i. Longsitting with legs extended

ii. Flex thoracic spine maximally and neck extended

iii. Contralaterally rotate and sidebend thoracic spine (away from pain)

iv. Apply Grade 3‐4 P to A force to ribs of suspected level of involvement

v. Positive: concordant sign reproduction local or remote, change with neck flexion

ROOS Adson’s Thoracic dural tension Rib compression

Sympathetic Slump

1

Thoracic Spine Management



Objectives

Describe the treatment interventions used for the management of pain from contractile and non-contractile tissue sourcescontractile tissue sources

Describe the treatment interventions used for the management of stiffness from contractile and non-contractile sources

Describe the treatment interventions used for the

management of instability of non-contractile sources

PAIN-DOMINANT TREATMENT

Pain-Dominant Treatment

Contractile– Myofascial pain syndrome

– Treatment prescribed asTreatment prescribed as for cervical spine, including progression

Non-contractile– T4 syndrome

– TOS

– Disc

T4 Management


Tissue specific Tissue specific guidelines– Graded mobilization

T3-5 – Graded ROM

Neural gliding Cervicothoracic spine,

opposite spinal curve

T4 Management


E i t i d d d Ergonomics on sustained and end range slumped postures

– Mechanical Underlying rib dysfunction (1-3 ribs)

into exhalation

Mobilization of hypomobile spinal segments above/below level

Stretching of hypertonic muscles (Upper trap/levator/scalenes)

Spinal/Scapular stabilization

2

Support for T4 Management

Case study (28 year old female, 2 months onset B UE, neck, head and upper back pain)

6 i it 3 k– 6 visits over 3 weeks

– Heavy emphasis postural education

– T4 Graded PAs in flexion (position of provocation)

– Referral to Pilates class (did not attend)

Outcome: Elimination of B UE, neck, and head pain by 4th visit, lost to long-term followup

– Conroy and Schneiders, Manual Therapy, 2005

TOS Management


Sinkus and Stragier 1994g

Tissue specific guidelines

– Graded AROM Neural gliding

– Crosby and Wehbe, Hand Clinics, 2004

TOS Management Contributing Impairments

Environmental– Ergonomics on correction of

depressed shouldersdepressed shoulders Cyriax release maneuver

before bed, up to 30mins

Gradual increase in sx before decrease

– Education on sleeping position Avoid overhead

Physical– Education on diaphragmatic

breathingHooper et al 2010

TOS Management Contributing Impairments

Mechanical– Mobilization of hypomobile

first rib, ACJ, SCJ**

– Stretching of hypertonic scalene/pec minor

– Mobilization/stabilization of facilitated cervical segment (C3/4) accounting for scalene hypertonicity

– Scapular stabilization*

– Taping into upward* rotation

*Watson et al 2010**Hooper et al 2010

Support for TOS Management

Interventions– ROM: Shoulder rolls and seated upper cervical flexion

– Stretching: Levator, UT, SCM, scalenes, pec minorStretching: Levator, UT, SCM, scalenes, pec minor

– Strengthening: Serratus anterior

Outcomes– Satisfied with outcome 88.1%

– CRLF test negative and a normal range of cervical spine motion 81.5%

– Grip strength normal if reduced at admission 64.9%

– Tinel’s sign normal if positive at admission 58.5% Lindgren, Arch Phys Med Rehabil, 1997

Disc Management

Tissue specific guidelines– Graded Axial distraction

Sizer et al 2001

– Graded ROM (direc. pref.)

Contributing impairments– Environmental

Ergonomics on sustained and end range postures

– Mechanical Mobilization of hypomobile

segments above/below level

Treatment of underlying instability spinal/scapular

3

Thoracic Traction Considerations

T1-3 use cervical setup at 30deg

T4-9 use cervical setup T4-9 use cervical setup with bolster under thoracic spine

T9-12 use lumbar setup with higher pelvic belt placement

– Grieve, Common Vertebral Joint Problems, 1988

STIFFNESS-DOMINANT TREATMENT

Classification Categories

Treatment-based system (Olson 2009)– Impairment-dominant treatment

Thoracic hypomobility Thoracic hypomobility Thoracic hypomobility with UE referred pain (T4 syndrome) Thoracic instability

Thoracic hypomobility with neck pain Thoracic hypomobility with shoulder impairments Thoracic hypomobility with low back pain


Immediate focus for hypomobile structures in and around the area of undifferentiated pain

Gradual inclusion for tissues transitioning from pain-dominant state– Contractile myofascial pain syndrome

Ischemic pressure and sustained end range stretching

– Non-contractile nerve and disc

Progression of Nerve Tissue

TOS/T4– Progress neural

glides to end rangeglides to end range positions

– Simultaneous mobilization of mechanical interface sites First rib

T4 in sympathetic slump position

Manipulation: Grade V technique– According to (Shekelle 1994), best for:

Entrapped synovial folds or plica

Mobilization vs Manipulation

Entrapped synovial folds or plica

Hypertonic muscle

Articular adhesions

Segmental displacement

– Technique may be accurately localized or globally applied (short vs long lever)

– Requires prepositioning at end range

– Applied one time (repeat once PRN if no cavitation)

4

Examples of Therapist-Administered Treatment

PAs– SP, TP

– CT, CCCT, CC

Inhalation/Exhalation– CT, CV

Rotation– TPs

Distraction– ZJ

Examples of Patient-Administered Treatment

Theracane/Tennis balls – Soft tissue and joint mobilization

upper thoracic spine and ribspp p

Supine foam roller– Extension T3 and below (flexion

syndrome)

– Horizontal for targeted stretch, including ribs (rotation syndrome)

– Vertical for regional stretch

Sidelying foam roller– 3-10 rib mobilization

Support for Soft Tissue Treatment

Population: 40 subjects with active trigger points

Intervention: HEP consisting of theracane selfIntervention: HEP consisting of theracane self mobilization and stretching versus neck ROM, 2x/d x 5days

Outcomes: Significant decrease in pain (VAS) and pressure pain threshold in mobilization group– Hanten et al, PT, 2000

Support for TSM for Thoracic Pain

Population: 30 patients with mechanical thoracic spinal pain

Intervention: US placebo versus spinal manipulation

Outcomes: Short term improvements in pain reduction and lateral flexion ROM; no difference at one month– Schiller, J Manip Phys Ther, 2001

PRIMARY INSTABILITY IMPAIRMENT


Immediate focus for joint instability with undifferentiated pain

Terminal classification for all tissues transitioning from pain-dominant state and hypomobility categories

5

Primary Treatment for Joint Instability


Ed ti li iti d Education on limiting end range positions, including rotation

– Mechanical Strengthening of Thoracic

spine away from syndrome

Stretching of CT and TL spine into syndrome

Motor control of Thoracic spine into syndrome

Examples of Primary Treatment for Instability

Independent activation/ Tonic hold

– Isometrics/isotonics ofIsometrics/isotonics of thoracic multifidus and scapular retractors (flexion syndrome)

– Isometrics/Isotonics of RA/IO and serratus (extension syndrome)


Integrated tonic hold– Supine lying trunk flexion

with cervical or lumbar emphasis (flexion syndrome)

– Prone lying trunk extension with cervical or lumbar emphasis (extension syndrome)


Integrated tonic hold (rotation syndrome)

P l i ith– Prone lying with scapular retraction/depression, neutral spine

– UE PRE Lee, Manual Therapy,

1996

Thoracic Treatment Lab

I. Pain‐dominance treatment

a. Centralization (See patient handouts)

i. Press ups

ii. Seated extension

iii. Quadruped flexion

iv. Prone on elbows flexion

II. Stiffness‐dominance treatment

a. Manual mobilization (time your mob/manip with patient’s exhalation)

i. Thoracic PAs

1. Same as exam, central or unilateral

2. Supine HVLA thrust

a. Patient reaches to opposite shoulders or

hands clasped behind head

b. Caudal hand in hook fist, eminences on one

row of TPs, fingertips on opposite row of TPs

c. Use cranial arm to flexes patient up to level

(flexion bias) or past the level (extension bias)

d. Lean onto patient’s trunk to take up slack

e. Manipulate with flexion or extension bias

i. Thrust in inferior/posterior direction

(flexion bias, good for flat mid thoracic)

ii. Thrust in superior/posterior direction

(extension bias, good for kyphosis and

required at CT junction)

ii. Thoracic physiological rotation

1. Prone HVLA thrust

a. Hypothenar eminences on adjacent TPs

with hands running across patient’s back

b. Use screw‐down mechanism to take up

tissue slack (hands should end up running up

patient’s back and arms should be crossed)

c. Lean onto patient’s trunk to take up additional

slack

d. PA thrust through both hands

2. CT junction rotation

a. Stand at patient’s head in power stance.

Patient should be resting on chin with nose

flattened

b. Hypothenar eminence on TP of segment

(arms should be crossed)

c. Take up soft tissue by pushing anterior/lateral through TP (in

the line of the levator muscle)

d. Rotate the patient’s head away until they are facing the side of

manipulation and you have created maximum locking out

e. Thrust anterior/lateral on TP

iii. Thoracic distraction HVLA thrust

1. Mid thoracic spine

a. Patient grasps their opposite shoulders

b. Therapist reaches to patient’s bottom arm

and cradles patient to achieve firm contact

against the levels to manipulate. Therapist

may stand off‐center as needed to achieve

firm contact.

c. Flex patient down and pull patient even

tighter into your chest

d. Rapid thrust through patient’s trunk moving posterior and

superior

2. CT junction distraction

a. Patient clasps hands behind head

b. Therapist reaches up under patient’s

armpits and squeezes their forearms

against the patient’s sides (therapist’s

hands can rest on patient’s forearms

or be free)

c. Therapist tightens forearm squeeze

and plants their chest into the levels to manipulate. Stance

may be off‐center to achieve best contact.

d. Keeping patient’s arms horizontally adducted, flex

patient down and scoop them into your chest to

achieve even tighter contact

e. Rapid thrust through patient’s trunk moving

posterior and superior

f. Alternate technique: Decrease emphasis on

forearm trunk squeeze and keeping patient’s arms

adducted. Instead, use patient’s arms as a lever

for taking up tissue slack.

iv. Rib PA

1. Prone

a. Same as test

2. Supine HVLA thrust

a. Stand on opposite

side of rib to be

manipulated

b. Caudal hand in gun

grip with tip of index

finger on SP, MCP on

rib head, and thenar

eminence on rib

angle

c. Cranial arm flexes patient up to level

d. Roll patient onto rib (past midline). Ensure maximum contact

of rib shared between MCP and thenar eminence.

e. Lean onto patient to take up slack. PA down with cranial arm

and trunk

v. Rib physiological inhalation/exhalation

1. Ribs 3‐10

a. Sidelying with treatment side up

b. Arm abducted until movement occurs

at site of dysfunction

c. Stuck in expiration: Mobilize the rib

below inferiorly. Take up tension with

increased GHJ ABD/inspiration

d. Stuck in inspiration: Mobilize the

dysfunctional rib inferiorly. Take up tension with increased GHJ

ABD/inhalation

2. First and Second rib exhalation mobilization

a. Same as exam

vi. First rib mobilization with neural gliding

1. Same rib mobilization as exam

2. Increase tension on system by sidebending

away and increasing UE ROM to the point of

symptom provocation

vii. Soft tissue mobilization

1. Medial scapular bordering

a. Put patient’s UE in IR reach position as needed

b. Maintain posterior scapular tilt and encourage upward rotation

c. Slide fingertips under scapula

d. Mobilize in direction of restriction

2. Pec minor

a. Sidelying with shoulder 90/90

b. Cranial hand mobilizes pec while

pulling superior scapula posteriorly

c. Caudal thumb encourages lateral

positioning of inferior angle

b. Self mobilization (See patient handouts)

i. CT spine

1. Tennis balls with cervical neutral, hands behind head

2. Unilateral tennis balls with rotation

3. Pec stretch

4. Tennis balls with CT extension

ii. Thoracic spine

1. Side stretch (rib superior glide)

2. Lat stretch

3. Foam roller for multisegment/soft tissue mobilization supine

4. Foam roller for multisegment/soft tissue mobilization sidelying

III. Weakness‐dominance treatment (See patient handouts)

a. Thoracic extension (thoracic flexion syndrome)

i. Tonic hold: Isometric thoracic extension

ii. Integrated tonic hold: Scapular retraction, Chest lift

b. Cervical‐lumbar flexion (thoracic flexion syndrome)

i. Tonic hold: Isometric craniocervical flexion

ii. Integrated tonic hold: Double leg lifts for lower abdominals

c. Thoracic flexion (thoracic extension syndrome)

i. Tonic hold: Isometric thoracic flexion

ii. Integrated tonic hold: Trunk curl with thoracic flexion emphasis

d. Cervical‐lumbar extension (thoracic extension syndrome)

i. Tonic hold: Isometric cervical retraction

ii. Integrated tonic hold: Trunk extension with trunk unsupported (lumbar focus)

e. Serratus

i. Tonic hold: Punches

ii. Integrated tonic hold: CKC push ups

iii. Integrated tonic hold or dynamic activation: Overhead press

f. Mid/Low trap

i. Tonic hold: Scapular retraction/depression with GHJ unsupported

ii. Integrated tonic hold: Scapular retraction/depression with GHJ flexion,

abduction

iii. Integrated tonic hold or dynamic activation: Snow angels

g. Upper trapezius

i. Tonic hold: Arms on wall, shrugs

ii. Integrated tonic hold: resisted shrugs with arms unsupported, overhead

iii. Integrated tonic hold or dynamic activation: High rows resisted

Julie DeVahl, MS, PT, OCSAssistant Professor

Department of Physical Therapy

Temporomandibular Disorders

Learning Objectives:

Conduct initial examination and classify patients with TMD.

Determine plan of care for patients with TMD.

Perform manual therapy for soft-tissue and joint restrictions.

Provide patient education for self-management.

Examination

History: – Chief complaint– Onset, mechanism of injury– Pain behavior patterns– Red flag screening– Medical interventions– Occupation– Activities of daily living– Recreational activities

Examination

Specific Questions may include:– Pain when talking, singing, yawning or chewing?– Clicking, popping or gravel noises in the jaw?– The feeling that your jaw catches or locks?– Problems opening or closing your mouth? – The habit of grinding or clenching your teeth?– A recent change in your bite? – Splint or night guard?– Dental history, including orthodontics?– Ear symptoms?

Examination

Specific Questions (cont’d)– Symptoms change (better or worse) with neck

movements?– Headaches? If yes, where do they start?– Neck, shoulder, or back pain?– Whiplash or recent injury to your head or neck?– Increased stress in your life?– A history of arthritis or other medical conditions?– Any prescription or over-the-counter medications,

herbs, or supplements?

Examination

Functional Questionnaires:– Jaw Functional Limitation Scale

Ohrbach et al, 2008

20 item version with good reliability and validity for assessing limitations in mastication, jaw mobility, verbal and emotional expression

8 item version for assessment of global functional limitation

– Temporomandibular Disorder Disability Index Streigerwald and Maher, 1997

No psychometrics available

Examination

What is the patient’s goal or expectation?

Checklist of Psychological and Behavioral Factors From McNeill 1990 in Dutton 2004

Inconsistent, inappropriate, or vague reports of pain

Over dramatization of symptoms

Symptoms that vary with life events

Significant pain of > 6 months’ duration

Repeated failures with conventional therapies

Inconsistent response to medications

History of other stress-related disorders

Major life events (e.g. new job, marriage, divorce, death)

Evidence of drug abuse

Clinically significant anxiety or depression

Evidence of secondary gain

Examination: Posture

Sitting and/or standing alignment– Occipital protuberance aligned with C7

– 2 finger-widths of space between base of occiput and C2

– McGregor’s plane is horizontal

– Forehead, lips and chin aligned (orthognathic) Retrognathic-posterior

Prognathic-anterior

Examination: Posture

Forward head posture is common– Adaptive: greater mandibular depression

– Maladaptive: functional malocclusion and spasm of the lateral pterygoid

Examination

Facial symmetry– Bottom 1/3 of face = top 1/3 of face

– Masseter hypertrophy or atrophy

Examination

Facial symmetry– Lat. eye-mouth = nose-chin

– Alignment of central incisors

Examination: AROM

Cervical – Examine c-spine gross and accessory

mobility prior to TMJ

– Can the patient keep the mouth closed during maximum flexion and extension? During cervical flexion: mandible moves up and forward

During cervical extension: mandible moves down and back

Examination

– Mandible AROM Depression-normal

opening3 Fingers

40 mm

Lateral deviation

(excursion)10 mm

Protrusion4-6 mm past upper incisors

(8-10 mm total)

Examination

Reliability (ICC)Standard Ruler Walker 2000

– Depression

Intra-rater reliability .94

Inter-rater reliability of .99

– Lateral deviation

Intra-rater reliability .75-.92

Inter-rater reliability of .94-.96

– Protrusion

Intra-rater reliability .89-93

Inter-rater reliability of .98

MDD =6 mmMagee 2008

Examination: AROM

– Mandible AROM1. Observe

2. Palpate

3. Measure

P

R L

O

Draw opening/closing pattern.Use “x” to mark joint soundsand “” to mark end range

Examination: AROM

Palpate condylar movement– Anterior to tragus

over condyle

– Posterior to tragus behind condyle

– 1# pressure used to palpate for tenderness

Examination: AROM

Auscultation– Click, pop, crepitus

– Document when it occurs

– Painful or not

Examination: PROM

Maximum Assisted Opening

PT uses thumb on maxillary incisors and index finger on mandibular incisors to assist with moderate pressure.

Examination: Strength

MMT– Grades 0-5/5

– Qualifiers:

Strong/pain free, Strong/painful, Weak/pain free, Weak/painful

Examination

Overpressure (end feel)– Normal: tissue stretch

– Abnormal Hard: osseous abnormalities

Springy: displacement of the disc

Capsular: adaptive shortening of the periarticular tissues

Examination: Accessory Motions

TMJ accessory motions– Distraction (inferior, caudal)

– Anterior glides

– Medial and lateral glides

Medial Lateral

Examination: Palpation

Muscle Palpation: – 2# pressure for extra-oral, 1# for intra-oral

– Mandible in rest position without teeth contact

– Press in multiple areas to locate tenderness

– Note:Hypertonus

Local tenderness

Referred pain


Temporalis– Posterior

– Middle

– Anterior


Temporalis tendon-intraoral along ramus of mandible– Use index finger pad


Masseter– Origin

– Body

– Insertion


Medial Pterygoid


Lateral Pterygoid


Accessory Muscles

SCM, Scalenes,Suboccipitals

Ant. Digastrics

Hyoid bone mobility(infrahyoids)

Examination: Special Tests

Jaw reflex: tap examiner’s thumb

Chvostek Test: tap parotid gland overlying masseter.– Positive test: facial

muscles twitch. Implicates involvement of CN VII.

Examination: Special Tests

Bite Test: place cotton roll or double tongue blades between molars and bite gradually; assess pain

– Ipsilateral pain-muscle/tendon irritation

– Contralateral pain-capsulitis/synovitis

– Test both sides to confirm

Diagnostic Value of Orthopedic Tests in TMD Lobbezoo-Scholte 1993

Tests Used1. Active movement (all directions)

2. Passive opening

3. Joint Play

4. Compression (manual)

5. Static pain test (MMT)

6. Palpation (muscles)

Diagnostic Value of Orthopedic Tests in TMD Lobbezoo-Scholte 1993

Distinguish Patient or Control– Passive opening (OR 20.6)

– Active movements and palpation (OR 35.6)

Distinguish Myogenous or Arthrogenous Patients– Active movements (OR 15.36)

Distinguish Internal Derangement or Osteoarthritis– Active movements (OR 80.0)

Distinguish ID w/ Reduction or w/o Reduction– Active movements (288.00)

Evaluation

PT Diagnosis– TMD Classification (Olson 2009)

Capsulitis/synovitisCapsular fibrosisMasticatory muscle disordersHypermobilityAnterior disc displacement with reductionAnterior disc displacement without reductionOsteoarthritis

Evaluation

Anterior disc displacement with reduction– Stage I:

Disc slightly anterior, little to no pain. Repetitive trauma begins to deform disc.

– Stage II: Reciprocal click early in opening and late in closing phase. Loss of integrity of ligamentous and intracapsular

structures, disc deformation and impingement May develop open lock

Evaluation

Anterior disc displacement without reduction– Stage III

Most painful stage

Reciprocal click occurs later in opening and earlier in closing

Closed lock-disc becomes lodged anteriorly (adhesions)

– Stage IV Clicking is rare, or single opening click

Chronic locking w/ soft-tissue remodeling

Ant. displaced disc common, but may be post.

Evaluation

Osteoarthritis

– Stage V Radiographic degenerative changes on condylar head

and articular eminences

Evidence of remodeling and osteophytes

Marked deformity and thickening of disc

Narrowed joint space

Research Diagnostic CriteriaDworkin and LeResche 1992

Axis I: Clinical TMD ConditionsGroup I:Muscle disorders

I.a. Myofascial Pain I.b. Myofascial Pain with Limited Opening (<40 mm)

Group II: Disc DisplacementsII.a. With reduction, normal openingII.b. Without reduction, limited openingII.c. Without reduction, normal opening

Group III: JointIII.a. Arthralgia-capsulitis/synovitisIII.b. Osteoarthritis-arthralgia and crepitisIII.c. Osteoarthrosis-absence of arthralgia

with bony changes

Interventions

Education– Rest Position of Jaw and Neck

Tongue tip on top (rugae)

Lips closed

Teeth parted

Erect posture

Diaphragmatic breathing

– Cervical Posture Sleep: supine preferred

Work/school/ADLs

Education

Soup

Smoothies

Milkshakes

Ice cream

Applesauce

Bananas

Gelatin

Eating Modifications– Soft foods include:

Scrambled eggs

Quiche

Baked fish

Yogurt

Tofu

Mashed potatoes

Pasta

Education

Eating Modifications– Don’t bite into foods such as:

Whole apples

Carrots or celery

Corn on the cob

Sandwiches with lettuce

Hamburgers

– Cut foods into bite-sized pieces

– Grind or finely chop meats or

other tough foods

Education

Eating Modifications– Avoid hard or chewy foods:

Nuts

Popcorn

Gum

Carmel

Gummy candies

Bread crusts or bagels

Ice

Education

Other Modifications– Support your jaw when yawning

“Tongue tip on top”

Manual support

– Avoid loud singing or yelling

– Avoid biting nails or pencils

For desk workers:– Headset

– Computer monitor at eye level

– Sit with good back support and don’t slouch

Interventions: Manual Therapy

Soft tissue techniques– Massage – longitudinal, cross friction or circular

SCM/Scalenes Submandibular Pterygoids/Masseter


Myofascial Release – take up the slack and hold (1-2 min)

Occipital Parietal/Temporalis

Masseter-elevation Masseter-depression


Myofascial Release

Ear Pull


Joint mobilization– Distraction-for pain

control, general joint mobility or reduce condylar head if it is displaced

– Distraction and anterior translation-improve opening and protrusion or reduce an anteriorly displaced disc


Joint mobilization– Lateral/Medial glides-prep

joint for ROM activities, break adhesions, stretch joint capsule or improve lateral deviation. Lateral-thumb on molars

(lingual side), fingers on mandible near front teeth

Medial-thumb near front teeth (lingual side), fingers on posterior mandible

Lateral

Medial

Interventions: Mobility Exercises

TMJ rotation and translation control– Restore proper tracking to the TMJ

– Decrease or eliminate clicking, popping or excessive movement

– Emphasize rotationPhase I: Active assisted-finger on chin and TMJ, tongue on top

Phase II: Active-fingers on TMJ, tongue on top

Phase III: Fingers in Phase I position, drop tongue at max opening

Phase IV: Fingers in Phase II position, drop tongue at max opening

Mobility: TMJ rotation and translation control “Turn the knob and open the door”

Phase I

Phase II

Phase III

Phase IV


Controlled ROM with Tongue Blade

– Requires visual cues with mirror

– Muscle re-ed and AROM post-op

– Initial training with tongue blade and progress to without Straight opening

Lateral deviation

Protrusion


PROM– Finger assisted method


PROM– Therabite

Atosmedical.com

Interventions: Stability Exercises

Phase I: one finger resistance in rest position– Lateral R and L, up, in, diagonal R and L


Phase II: one finger resistance with opening one knuckle width

Phase III (opt): one finger resistance with opening two knuckles wide


Rhythmic Stabilization: resist depression/ elevation in neutral – Progress to one

knuckle width

Rocabado 6x6 Program

6 exercises, 6 reps, 6x/day1. Tongue Clucks

Promotes correct rest position

2. Controlled TMJ Rotation on Opening

Promotes rotation and prevents excessive protrusion

3. Mandibular Rhythmic Stabilization

Promotes normal position of jaw with proper postural alignment

Rocabado 6x6 Program

4. Upper Cervical DistractionRelieve neurovascular compression by distracting occiput from atlas

5. Axial Extension of Cervical Spine

Normalize posture

6. Shoulder Girdle Retraction & Depression

Normalize posture

Impairments: Posture-related

Education

Soft-tissue mobilization

Posture exercises (Wright, et al 2000)

Myofacial classification (>6 mos)

3 visits

Signif. improvement in MMO, Sx severity, PPT, perceived improvement

Impairments: Cervical Muscle Endurance

Flexors (Armijo-Olivo, et al. 2010)

Extensors (Armijo-Olivo, et al. 2012)

Interventions: Modalities

Home: heat and/or cold, TENS Clinic

– US– E-stim: IFC, iontophoresis – Spray and Stretch– EMG biofeedback– Low Level Laser

Interventions: Modalities

TENS electrode placements

Interventions: Modalities Post-operative Considerations

Arthrocentesis

Arthroscopy

Arthroplasty with or without Autograft

Partial or Complete Joint Replacement

Occlusal Splints

Common intervention used by dentists

Goal- create single contact for all posterior teeth

Evidence does not support general use for nonacute TMD, bruxism and headaches

1

Lab Activities for TMD

I. Observe cervical posture and facial symmetry A. Side view: ortho-, retro-, prognathic? B. Frontal view:

1. Upper 1/3 vs lower 1/3 2. Nose-eye = nose-chin 3. Masseter bulk

C. Supine: cranial-caudal

II. Mandibular range of motion A. Observe pattern of movement (depression, elevation, protrusion, lateral

deviation) Midline? S or C curve? Deviation? B. Auscultation: silent, clicks, crepitus C. Measure active range of motion:

depression, lateral deviation R/L and protrusion-Therabite ruler

Depression= R lat dev= L lat dev= Protrusion=

D. Measure passive depression.

III.Palpation (self and partner) A. Lateral and posterior joint capsule

1. At rest for tenderness 2. During movement for motor control, joint noises

B. Extraoral trigger points: Masseter, Temporalis, Digastric,

C. Intraoral palpation:

Masseter Temporalis tendon, Lateral and Medial Pterygoid (ramus of condyle)

2

IV. Manual Muscle Test of mandibular musculature A. Depression B. Elevation C. Lateral deviation

V. Special Tests

Forced retrusion Bite test

VI.Mandibular accessory motion

Distraction Medial glide Lateral glide

Distraction and anterior translation

Mobilization is the same as accessory motion testing. Oscillations vs holds

VII. Soft-tissue Intervention Techniques A. Massage

Masseter Supra/Infrahyoids SCM

B. Myofascial release

Occipital Parietal (2 phases) Masseter (2 phases)

Ear Pull

3

VIII. Mobility Exercises (see ROM handout) A. TMJ rotation and translation control- 4 phases B. Tongue blade-depression/elevation, lateral deviation, protrusion C. Passive stretching-finger pressure and tongue blades D. Tube exercises for proprioception (see Tubing handout)

IX. Stability Exercises (see Rocabado 6x6 handout) A. Manual resistance (1 finger)- 2-3 phases B. Rhythmic stabilization

4

TMD Cases and Problem Solving (adapted from Olson KA. Manual Physical Therapy of the Spine, 2009)

Case 1 History A 23 year old college student has tightness, discomfort and clicking in the right TMJ with intermittent occipital headaches. Pain is provoked with stressful situations and with chewing meat and crunchy foods. Test and Measures

Posture: moderate forward head posture with protracted scapulae AROM:

o Cervical (in standing): 85% in all planes of motion and pain free except for extension, which is 50% and provokes occipital area pain

o Thoracic: 75-85% in all planes of motion and pain free o Mandible: opening to 35 mm with mid range deviation to the right and

return to midline after opening joint sound (also noted at mid range closing. Lateral deviation right 10 mm, left 5 mm. Protrusion 5 mm with midrange click.

o Shoulder screen: full and pain free bilateral shoulder AROM Passive intervertebral motion (PIVM) testing: limited craniovertebral flexion, right

side bending, and left rotation; mid cervical spine PIVM testing reveals hypermobility; upper thoracic is slightly restricted at T1-T2 left and right rotation, and flexion.

Muscle length: mild tightness right levator scapula and minimally tight bilateral pectoralis major and minor

Strength: lower and middle trapezius are 4-/5; deep neck flexors are 3+/5 Neurological screen: negative Special tests:

o Bite test: painful right TMJ with biting on the left side o Retrusive overpressure: provokes pain on right TMJ

Palpation: tender and guarded right muscles of mastication with intraoral and extraoral palpation, tender at lateral pole right TMJ; tender at C2-C3 right facet joint

Evaluation

Diagnosis:

Impairments:

Prognosis:

Interventions: Goals:

5

Case 2 History A 50 year old construction worker has difficulty opening his mouth after trauma from being hit in the jaw during a bar fight 3 months prior to the initial evaluation. The patient has no history of TMJ sounds. Recent radiographic results were negative for signs of mandibular fracture. Tests and Measures

Posture: mild forward head posture with protracted scapulae AROM:

o Cervical in standing: 85% in all planes of motion and pain free o Thoracic: 75% upper thoracic rotation motion and pain free o Mandible: 20 mm opening with deviation to the right, lateral deviation right

7 mm, left 4 mm; protrusion 3 mm with deviation to the right; no joint sounds noted

o Shoulder screen: full ROM and normal strength Accessory motion testing TMJ: hypomobility with lateral and medial glide and

joint distraction right TMJ PIVM testing: slight hypomobility craniovertebral flexion and right side bending;

hypomobility T1-T2 left and right rotation Muslce length: no limitations noted Strength lower and middle trapezius are 4-/5; deep neck flexors are 3+/5 Neurologic screen: negative Special tests:

o Bite test: negative o Retrusive overpressure: negative

Palpation: tender and guarded right muscles of mastication intraoral and externally, and tender at right lateral mandibular condyle

Evaluation

Diagnosis:

Impairments:

Prognosis:

Interventions: Goals:

Jaw Functional Limitation Scale

For each of the items below, please indicate the level of limitation during the last month. If the activity has been completely avoided because it is too difficult, then circle ‘10'. If you avoid an activity for reasons other than pain or difficulty, then leave the item blank.

No limitation

Severe Limitation

1. Chew tough food 0 1 2 3 4 5 6 7 8 9 10

2. Chew hard bread 0 1 2 3 4 5 6 7 8 9 10

3. Chew chicken (for example, preparedin oven) 0 1 2 3 4 5 6 7 8 9 10

4. Chew crackers 0 1 2 3 4 5 6 7 8 9 10

5. Chew soft food (for example, macaroni,canned or soft fruits, cooked vegetables,fish)

0 1 2 3 4 5 6 7 8 9 10

6. Eat soft food requiring no chewing (forexample, mashed potatoes, applesauce, pudding, pureed food)

0 1 2 3 4 5 6 7 8 9 10

7. Open wide enough to bite from a wholeapple

0 1 2 3 4 5 6 7 8 9 10

8. Open wide enough to bite into asandwich

0 1 2 3 4 5 6 7 8 9 10

9. Open wide enough to talk 0 1 2 3 4 5 6 7 8 9 10

10. Open wide enough to drink from a cup 0 1 2 3 4 5 6 7 8 9 10

11. Swallow 0 1 2 3 4 5 6 7 8 9 10

12. Yawn 0 1 2 3 4 5 6 7 8 9 10

13. Talk 0 1 2 3 4 5 6 7 8 9 10

14. Sing 0 1 2 3 4 5 6 7 8 9 10

15. Putting on a happy face 0 1 2 3 4 5 6 7 8 9 10

16. Putting on an angry face 0 1 2 3 4 5 6 7 8 9 10

17. Frown 0 1 2 3 4 5 6 7 8 9 10

18. Kiss 0 1 2 3 4 5 6 7 8 9 10

19. Smile 0 1 2 3 4 5 6 7 8 9 10

20. Laugh 0 1 2 3 4 5 6 7 8 9 10

Ohrbach R, Larsson P, List T. The jaw functional limitation scale: development, reliability, and validity of 8-item and 20-item versions. J Orfac Pain. 2008;22:219-230.

Temporomandibular Disorders Classification

Adapted from Olson KA. Manual Physical Therapy of the Spine. 2009

Classification ROM Accessory Motion Pain Palpation Joint Sounds

Capsulitis/Synovitis Variable-often limited

by pain

Pain with testing Bite on opposite side

Retrusive overpressure

Accessory motion

testing

Tender over lateral

and posterior condyle

None

Capsular Fibrosis <25 mm

Deviates toward

involved side

Hypomobile Mild-none at rest

Pain at end range

Variable None

Masticatory Muscle AROM<PROM Normal Bite on same

Chewing, eating

Tender/spasm of

masseter, temporalis,

lateral pterygoid

None

Hypermobility >40 mm (subluxation)

>60 mm (dislocation)

Hypermobile Unually none Negative At end range

Anterior Disc Displacement

With Reduction

Normal opening with S

curve

Normal Variable Negative Reciprocal click

Anterior Disc Displacement

Without Reduction

<25 mm

Deviates toward

involved side

Hypomobile Generally pain at rest

and movement

Variable None

Osteoarthritis Limited AROM=PROM Hypomobile Variable Usually negative Crepitus

Temporomandibular Disorder Disability Index

Please check the statement that best pertains to you (not necessarily exactly) in each of the following categories.

Adapted from Streigerwald DP, Maher JH: The Streigerwald/Maher TMD disability questionnaire. Today Chiropract 23.86.91. 1997

1. Communication (talking) ___ I can talk as much as I want without pain, fatigue, or discomfort. ___ I can talk as much as I want, but it causes some pain, fatigue or discomfort. ___ I can’t talk as much as I want because of pain, fatigue or discomfort. ___ I can’t talk much at all because of pain, fatigue, or discomfort. ___ Pain prevents me from talking at all.

2. Normal living activities (brushing teeth/flossing) ___ I am able to care for my gums and teeth in a normal fashion without restriction and without pain, fatigue or discomfort. ___ I am able to care for all my teeth and gums, but I must be slow and careful, otherwise pain/discomfort or jaw tiredness results.

___ I do manage to care for my teeth and gums in a normal fashion, but it usually causes some pain/discomfort or jaw tiredness no matter how careful I am. ___ I am unable to properly clean all my teeth and gums because of restricted opening or pain. ___ I am unable to care for most of my teeth and gums because of restricted opening or pain.

3. Normal living activities (eating, chewing) ___ I can eat and chew as much of anything I want without pain/discomfort or jaw tiredness. ___ I can eat and chew most anything I want, but it sometimes causes pain/discomfort or jaw tiredness. ___ I can’t each much of anything I want because it often causes pain/discomfort or jaw tiredness or because of restricted opening. ___ I must eat only soft foods (consistency of scrambled eggs or less) because of pain/discomfort, jaw fatigue, or restricted opening. ___ I must stay on a liquid diet because of pain or restricted opening.

4. Social/recreational activities (singing, playing musical instruments, cheering, laughing, social activities, playing amateur sports/hobbies etc.)

___ I am enjoying a normal social life or recreational activities without restriction. ___ I participate in a normal social life or recreational activities, but pain/discomfort is increased. ___ The presence of pain or fear of likely aggravation only limits the more energetic components of my social life (sports, exercise, dancing, playing musical instruments singing). ___ I have restrictions socially as I can’t even sing, shout, cheer, play, or laugh expressively because of increased pain/discomfort. ___ I have practically no social life because of pain.

5. Nonspecialized jaw activities (yawning, mouth opening, and opening my mouth wide)

___ I can yawn in a normal fashion, painlessly. ___ I can yawn and open my mouth fully wide open, but sometimes there is discomfort. ___ I can yawn and open my mouth wide in a normal fashion, but it almost always causes discomfort. ___ Yawning and opening my mouth wide are somewhat restricted by pain. ___ I cannot yawn or open my mouth more than two finger widths (2.8 to 3.2 cm) or, if I can, it always causes

greater than moderate pain.

6. Sexual function (including kissing, hugging, and any and all sexual activities to which you are accustomed) ___ I am able to engage in all my customary sexual activities and expressions without limitation or causing headache, face, or jaw pain. ___ I am able to engage in all my customary sexual activities and expressions, but it sometimes causes some headache, face, or jaw pain or jaw fatigue. ___ I am able to engage in all my customary sexual activities and expressions, but it usually causes enough headache, face, or jaw pain to markedly interfere with my enjoyment, willingness, and satisfaction. ___ I must limit my customary sexual activities and expressions because of headache, face, or jaw pain, or limited mouth opening. ___ I abstain from almost all sexual activities and expression because of the head, face, or jaw pain it causes. 7. Sleep (restful, nocturnal sleep patterns) ___ I sleep well in a normal fashion without any pain medication, relaxants, or sleeping pills. ___ I sleep well with the use of pain pills, anti-inflammatory medication or medicinal sleeping aids. ___ I fail to realize 6 hours of restful sleep even with the use of pills. ___ I fail to realize 4 hours of restful sleep even with the use of pills ___ I fail to realize 2 hours of restful sleep even with the use of pills. 8. Effects of any form of treatment, including, but not limited to, medications, in-office therapy, treatments, oral orthotics (e.g., splints, mouthpieces), ice/heat, etc. ___ I do not need to use treatment of any type to control or tolerate headache, face or jaw pain and discomfort. ___ I can completely control my pain with some form of treatment. ___ I get partial, but significant, relief through some form of treatment. ___ I don’t get “a lot” of relief from any form of treatment. ___ There is no form of treatment that helps enough to make me want to continue. 9. Tinnitus, or ringing in the ear(s) ___ I do not experience ringing in my ear(s). ___ I experience ringing in my ear(s) somewhat, but it does not interfere with my sleep or my ability to perform my daily activities. ___ I experience ringing in my ear(s) and it interferes with my sleep or daily activities, but I can accomplish set goals and can get an acceptable amount of sleep. ___ I experience ringing in my ear(s), and it causes a marked impairment in the performance of my daily activities or results in an unacceptable loss of sleep. ___ I experience ringing in my ear(s) and it is incapacitating or forces me to use a masking device to get any sleep. 10. Dizziness (lightheadedness, spinning, or balance disturbance) ___ I do not experience dizziness. ___ I experience dizziness, but it does not interfere with my daily activities. ___ I experience dizziness that interferes somewhat with my daily activities, but I can accomplish my set goals. ___ I experience dizziness that causes a marked impairment in the performance of my daily activities. ___ I experience dizziness that is incapacitating.

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