CervicoThoracic EVALUATION.ppt CervicoThoracic EVALUATION

CervicoThoracic EVALUATION

1. Cervical-Throacic Evaluation and
Treatment
Development of a Clinical Prediction
Rule
DR.ABDUL RASHAD

2. Special Tests
•Debate in the meaningfulness and usefulness of
Vertebral Artery Testing
•Interpretation of a negative test
•If positive, further evaluation is indicated

3. Vertebral Artery Test
•Combined Movements
to stress test the
cervical spine
•Symptoms:
–Dizziness
–Lightheadedness
–Nystagmus
–Dysarthria
–Diplopia
–Dysphagia

4. Cervical Distraction
•Nerve Root
Compression
•Radicular pain is
decreased, test is
positive

5. Cervical Compression Test
•Pressure downward
on head
•Test is positive if pain
is evoked

6. Spurling A
•Seated
•Neck Side bent to the
ipisilateral side
•7kg of overpressure
applied
•Presence of pain,
parasthesial or
numbness

7. Spurling B
•Seated
•Extension
•Sidebending and
Rotation to the
ipsilateral side
•7kg of axial pressure is
applied

8. Sharp –Purser Test
•Neck in semi flexion
•Palm of one hand on
forehead
•Index finger on
Spinous process C2
•Posterior force
through forehead
•Posterior slide is + for
AA instability

9. Shoulder Abduction Sign
•Most common nerve
root compression at
C5-6
•Decrease in symptoms
is positive response

10. Median Nerve Testing
•Shoulder Retraction
and Depression
•Shoulder Extension
•External Rotation
•Elbow Extension
•Forearm Supination
•Wrist/Finger Extension

11. Radial Nerve Testing
•Proximal as for
Median
•Shoulder Internal Rot
•Forearm Pronation
•Wrist Flexion
•Ulnar Deviation
•Finger Flexion

12. Ulnar Nerve Testing
•Shoulder Retraction
•Shoulder Ext and ER
•Elbow Flexion
•Forearm Supination
•Wrist Extension and
Radial Deviation
•Finger Extension

13. Thoracic Outlet
•Roos Test
–Standing Abduct arm
to 90°
–ER shoulder
–Open and Close hand
for 3 minutes
•Positive if unable to
maintain position or
heaviness/tingling in
arm

14. Thoracic Outlet
•Adson Maneuver
•Sitting
•Palpate Radial Pulse
•Abduct, Extend and ER
arm
•Take deep breath and
rotate toward arm
•+ Subclavian if change
in radial pulse

15. Cervical Evaluation

16. Determining Severity
•Stage 1
–Inability to perform basic mechanical functions
•Stand for 15 minutes
•Sit for 15 minutes
•Walk greater than ¼ mile

17. Stage 1 Treatment
•Joint Manipulation\Mobilization
•Traction
•Active Spinal Movement
•Sleeping Postures
•NSAIDS
•Physical Agents
•Cervical Collar (rest from function only)

18. Determining Severity
•Stage II
–Unable to carry out ADL’s
•Vacuum, lift, push, pull
Treatment
–Posture
–Body Mechanics
–Active Exercise

19. Determining Severity
•Stage III
–Can perform ADL’s and high demand for brief time periods
–Cannot return fully to high demand activities
•Sports, occupational duties, deconditioned
•Treatment- Return to work/play
–Ergonomic Assessment/Modifications
–Endurance

20. Range of Motion
•Flexion
•Extension
•Sidebending
•Rotation
–Note quantity
–Quality (deviations/location)
–Symptom provocation
–Active and Passive overpressure
•Clear the shoulder (pain free ROM)

21. Upper Quarter Screen
•Spurling’s
•Hoffman’s Reflex
•L’hermittes
•Reflexes
•MMT
•Sensory Testing

22. Consider Disc
•True limitation in cervical flexion
•Radiculopathy recreated with motion
•Neurological findings
–Refer for MRI

23. Cervical Evaluation
•Passive Range of Motion with endfeel
•Joint Play
–Central PA glides
–Prone unilateral PA’s (facet glides)
–Can perform in Neutral, Flexion and Extension

24. Upper Thoracic Manipulation
•CT junction
•Patient sits far back on
table
•Stabilize shoulders
•Use their hands as
fulcrum
•Distract upwards
–Drop down

25. Early Treatment for Pain
•Rest
–Throughout day, interrupt activity
•Supported Sleep
–Butterfly pillow (good cervical pillow)
•Upright Posture
–Avoid hanging head
–Collar As Needed

26. Stage II Treatment
•Improve Range
–Joints, muscles, neural tissue
•Improve Stability
–Strengthen weak muscles
–Improved Postural Control
•Improve Aerobic Capacity
–Activity endurance

27. Self Stretching/Joint Mobs
•Use hands to stabilize cervical spine
•SNAG’s with towel

28. Indication for Cervical Manipulation
•Most successful in presence of a specific restriction
(primarily mechanical block)
•TTenderness
•A Asymmetry
•R Restriction of Movement
•T Tension (muscle and soft tissue)

29. Contraindications to Manipulation
•Paget’s Disease
•Rheumatoid Arthritis
•Osetomyelitis
•Ankylosing Spondylitis
•Malignancy
•Cord and Cauda Equina Syndrome
•Vertebral Artery Involvement

30. Complications Resulting from Treatments
of the C-spine
Treatment Complication
•Manipulation Major
Complication or Death
–5-10/10,000,000
•Cervical Surgery
–15.6/1000 Neurological Compromise
–6.9/1000 Death
•NSAIDS Serious GI event
3.2/1000 (age 65+) Bleeding, perforation, or other
.39/1000 (<65) resulting in hospitalization or death
1/1000 (Ages combined)

31. Examination
•Perform an Upper Quarter Screen
–Check dermatomes
–Check myotomes
–Check reflexes

32. Range of Motion
•Cervical spine facet motion
–Flexion causes facet opening
–Extension causes facet closing
–Rotation and Lateral Flexion occur in the same direction
–Rotation and Lateral Flexion cause facet opening
contralerally and closing ipsilaterally

33. Cervical Facet Opening/Closing
•Maximal Left Opening
–Forward Flexion
–Right Rotation
– Right Sidebending
•Maximal Left Closing
–Extension
–Left Rotation
–Left Sidebending

34. Cervical Manipulation Procedure
•Position patient comfortably
•Palpate the cervical treatment level
•Flex or Extend the neck until
tension/approximation is noted at the spinal
interspace above the desired level
•Rotate the head to end range
•During patient exhalation - stress end range
•Quickly overpress when the patient relaxes
•Reassess the patient’s movement and record

35. Manipulation Position for Right
Cervical Closing

36. Alternative to Manipulation
•Follow the outlined treatment(no overpress)
–Oscillate the head at end range
•Traction (manual or mechanical)
•Soft tissue Treatment
–Modalities
–Massage
•Seek training with skilled manipulator
•Refer patient to skilled manipulator

37. Myth of Manipulation
•Manipulation is not
–Dealing with dislocation/subluxation
–Correcting a “little bone out of place”
–Restoring a “slipped disc”
•Manipulation is
–Designed to overcome a motion restriction

38. Provocative Tests
•Induce or alleviate mechanical pressure
•Enlarge neural foramen
•Stretch neural elements

39. Wainner Spine 2003
•Provocative Testing
–Spurling
–Shoulder Abduction Test
–Valsalva Maneuver
–Neck Distraction

40. Cervical Lateral Glides

41. Thoracic Manipulations

42. Randomized Treatment
•Thoracic manipulation

43. Intervention
•3 Thrust
Manipulations
–2 reps of each
•Seated Distraction

44. Intervention
•Supine Upper Thoracic
Manip

45. Intervention
•Supine Middle
Thoracic Manipulation