Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks PT, PhD Cervical-Throacic Evaluation and Treatment Development of a Clinical Prediction Rule Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks PT, PhD

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

Vertebral Artery Test Combined Movements to stress test the cervical spine Symptoms: Dizziness -Tinnitus Lightheadedness Nystagmus -Parathesia Dysarthria - Diplopia Dysphagia

Vertebral Artery Preliminary Test Patient is sitting. Sustain cervical extension for 10 seconds. Sustain Rotation (L and R) 10 seconds IF POSITIVE STOP If the testing is negative progress to standard position.

Vertebral Artery Standard Test Patient is supine. Sustain cervical extension for 10 seconds. Sustain Rotation (L and R) for 10 seconds Combine Extension with Rotation (L and R) for 10 seconds. Test the patient in the manipulation position IF POSITIVE STOP, do not manipulate

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

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

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

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

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

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

Median Nerve Testing Shoulder Retraction and Depression Shoulder Extension External Rotation Elbow Extension Forearm Supination Wrist/Finger Extension Cervical SB and Rot Away

Upper Limb Tension Testing A Scapular Depression Shoulder Abduction Shoulder ER Elbow Extension Forearm Sup Wrist and Finger Extension

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

Upper Limb Tension Testing B Supine in 30º Abd Scap Depression Shoulder IR Elbow Extension Wrist and Finger Flexion Opposite Cervical SB and Rot

Ulnar Nerve Testing Shoulder Retraction Shld Ext and ER Elbow Flexion Forearm Supination Wrist Extension and Radial Deviation Finger Extension Cervical SB and Rot away

T1 Nerve Root Stretch Abduct to 90º Flex pronated arms to 90º Flex elbows and place behind the neck Pain in scapular area is T1- Pain in Ulnar distribution is Ulnar

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

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

Thoracic Outlet Halstead Maneuver Palpate radial pulse and distract UE Patient extends and rotates cervical spine to opposite side Positive for TOS if absence of pluse

Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks PT, PhD Cervical Evaluation Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks PT, PhD

Determining Severity Stage 1 Inability to perform basic mechanical functions Stand for 15 minutes Sit for 15 minutes Walk greater than ¼ mile Cervical Oswestry (NDI) ≥ 30% Often as high as 50% (less than 2 wks otherwise r/o symptom magnification) Tx- Pain modulation and movement

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

Determining Severity Stage II Treatment Unable to carry out ADL’s Vacuum, lift, push, pull Oswestry (NDI) 20-30% Treatment Weakness Tightness Posture Body Mechanics Active Exercise

Determining Severity Stage III Treatment- Return to work/play Can perform ADL’s and high demand for brief time periods Cannot return fully to high demand activities Sports, occupational duties, deconditioned Cervical Oswestry(NDI) ≤ 20% Treatment- Return to work/play Ergonomic Assessment/Modifications Endurance

Assessment of Movement Cyriax Capsular Pattern Full flexion, limited extension and symmetrically limited rotation and sidebending Arthritis, inflammation or DJD of the joints Flexion is not significantly involved since the neck tolerates flexion well Restricted flexion Upper Thoracic and Cervicothoracic junction

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

Non capsular pattern Flexion is limited (non capsular) Often cervicothoracic or upper thoracic jxn Opening Restrictions Closing Restrictions Combination Restrictions Significant dysfunction Located 2 or more areas Compensations

Referred Symptoms Closing Restriction Extension and Sidebending reproduce sx’s Limited Cervical Flexion and symptoms Not typical decreased cervical flexion with symptoms in upper back Sidebending to opposite side produces distal symptoms

Upper Quarter Screen Spurling’s Hoffman’s Reflex (Babinski of UE) L’hermittes Reflexes MMT Sensory Testing

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

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

Response to Range of Motion Capsular Pattern (No Radiculopathy)? Yes Determine Stage and Treat Stage I Mobs, Traction, Modalities, NSAIDS, Sleeping Postures Stage II Active Exercise, Postural Correction, Daily Activities Stage III Ergonomic Assessment and Modifications

Response to ROM No Capsular Pattern Is Flexion Limited? No Yes Is there an opening Restriction? Assess and Tx C-T and T jxn Yes No Joint Mobs for opening Is there a Closing Restriction? Yes No Likely a combined lesion Joint Mobs for closing

Limited Forward Flexion Traction Manip to C-T Junction and Thoracic Full Passive Flexion (see next) Forward Flexion Still Limited Try Cervical Traction Improve: Continue No Change: MRI for mechanical block

Full Flexion Opening Restriction No Radicular SXs during movement Opening Manipulation +TOS signs -TOS signs Joint Mobs for opening Traction Manipulation +Radicular SXs on Opening -Radicular SXs on Opening Opening Manipulation ICT

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

Thoracic Outlet Clavicle, 1st Rib and Costoclavicular lig, subclavius and ant scalene Compression of subclavian or axiallary artery, vein, or brachial plexius (C8 and T1) Costoclavicular syndrome Loss space between clavicle and 1st rib Cervical Rib (<1%) syndrome Cervical rib from C7 or band of fibrous tissue in area

Thoracic Outlet Anterior Scalene Syndrome Compression of neurovascular bundle between anterior and middle scales Tingling 4th and 5th digit Ulnar and Median weakness If vascular hand edema Testing should recreate symptoms Vascular change alone is not predictive Exacerbated by shoulder hypermobility Dead arm

Full Flexion and Closing Restriction No Radicular Symptoms on closing Closing Manipulation

Full Flexion and Closing Restriction Radicular symptoms on closing + Neuro Signs - Neuro Signs Traction Manip Opening Manip + Radicular with Closing Radicular with Closing + Radicular with Closing - Radicular with Closing ICT Closing Manip Traction Manip Closing Manip

Early Treatment for Pain 3 Finger Treatments- Painfree ROM Neck Retraction Lateral Flexion Rotation Decrease flexion (increase fingers) as pain subsides

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

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

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

Indication for Cervical Manipulation Most successful in presence of a specific restriction (primarily mechanical block) T Tenderness A Asymmetry R Restriction of Movement T Tension (muscle and soft tissue) Bourdillon 1970

Differential Diagnosis History Fracture or Instability Index of Suspicion Intoxication, LOC, High Energy Injuries x-rays lateral(flex/ext),AP,open mouth,obliques Osteophytic Encroachment Whiplash(acceleration injury)

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

Complications Due to Manipulation Neurovascular Complications Author Cases Sherman, Smialek &Zane 52 Grant 58 Patijin 84 Terrett 107 Kunnasmaa & Thiel 139 (Rivett, Milburn 1996)

Lee et al. Neurology 1995 Survey of 177 Neurologists Report of neurologic complications following chiropractic manipulation 102 Complications 56 Strokes 13 Myelopathies 22 Radiculopathies

Hurtwitz et al. 1996 Spine Complication Rate 5-10 in 5 to 10 million Less than 120 cases in English Primarily Vertebrobasilar accident (VBA) Brain stem or cerebellar infarct Cord compression, Fracture, Tracheal rupture Diaphragm paralysis, carotid hematoma or cardiac arrest

Injury on 118 Complications Initial Complaints 37 (31.5%) Neck Pain 10 (8.5%) Neck stiffness 17 (14.5%) Head and neck pain or stiffness 23 (19.5%) Headaches 31 (26%) Other Torticollis, back pain, head colds

Injury in Manipulation 82% were rotational manipulations 66% had signs or symptoms of VBA After first manipulation 78% had consequences of VB ischemia 20 died 42 had residual symptoms Risk for Mild complication 1 in 40,000 Risk for Serious complication 1 in 1 million

Complications Resulting from Treatments of the C-spine Treatment Complication Manipulation VBA, 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)

Examination Perform an Upper Quarter Screen Check dermatomes Check myotomes Check reflexes

Range of Motion Cervical spine facet motion Flexion causes facet opening Extension causes facet closing Rotation and Lateral Flexion(SB) occur in the same direction Rotation and Lateral Flexion cause facet opening contralerally and closing ipsilaterally

Cervical Facet Opening/Closing Maximal Left Opening Forward Flexion Right Rotation Right Sidebending Maximal Left Closing Extension Left Rotation Left Sidebending

Treatment/Manipulation To Open or Close? Force a stuck drawer close Open the drawer fully and then attempt to close it

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

Manipulation Position for Right Cervical Closing

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

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

Cervical Radiculopathy

Cervical Case

Reliability and Accuracy of Clinical Exam for Cervical Radiculopathy Wainner Spine 2003 82 Patients with suspected Cervical radiculopathy or carpel tunnel Electrophysiological Testing Nerve Conduction Study Needle Electromyography Clinical Exam 34 items and 2 raters

Wainner Spine 2003 Data Collected Visual Analog Scale NDI History Questions MMT of Upper Quarter Reflexes Pin prick sensation Cervical ROM 2 warm up- 1 trial with inclinometer

Provocative Tests Induce or alleviate mechanical pressure Enlarge neural foramen Stretch or slacken neural elements Increase intrathecal pressure

Wainner Spine 2003 Provocative Testing Spurling A Spurling B Shoulder Abduction Test Valsalva Maneuver Neck Distraction Upper Limb Tension A and B

Cervical Radiculopathy Upper Limb Tension Test A (symptoms recreated, ≥10° elbow ext. difference or wrist flexion, cervical SB’ing increases sx.) Involved Cervical Rotation less than 60 degrees Distraction Test (Supine examiner distracts- symptoms reduced) Spurling A (Sidebend with compression)

Cervical Radiculopathy Upper Limb Tension Test A Involved Cervical Rotation of less than 60° Distraction Test (Reduces symptoms) Spurling A ( if negative best to rule out) 2 Tests = 21% 3 tests= 65% 4 Tests= 90% Reference Criterion- Electrophysiological Testing

Radiculopathy Treatment Cleland JOSPT 2005 Diagnosis based on Wainner et al. Case Series of 10 patients 6 month Follow up

Subjects 11 of 28 satisfied criteria Age =  51.7 (S.D. 8.2) Symptom Duration=  18 weeks (8-52) Treatments =  7.1 (6-10) 9 of 11 had neck & upper extremity pain(82%)

Treatment Cervical and Thoracic Mobilizations Deep neck flexor Supine flattening cervical lordosis with nod 10 second hold/ 10 reps Scapular exercises Middle and Lower trap (prone on plinth) Serratus Wall push ups Mechanical traction to centralize or reduce sx’s Intermittent 30:10 for 15 minutes 8.2 kg (18lbs) increased .5-1kg/visit

Cervical Lateral Glides

Thoracic Manipulations

Outcomes Discharge: 8 of 11 (73%) were negative on cluster of tests 2 had positive Spurling’s but improved function 1 had ULTT and Suprling’s 10 Patients (91%) had clinically meaningful reductions in pain and disability (> 2-7pt change) Lasted for 6 months- 45 % had 10/10 50% had mild limitations

Expand Criteria If treatment aimed at thoracic helps with radiculopathy- how about neck pain?

Subjects Primary Complaint of Mechanical Neck Pain NDI VAS (0-100) Nonspecific pain in cervicothoracic jxn worsened with neck movements NDI VAS (0-100) 36 subjects

Randomized Treatment Thoracic manipulation Sham Manipulation

Immediate Response to Manipulation

Clinical Prediction Rule Which patients with neck pain can benefit from thoracic manipulation, exercise, and patient education? Cleland et al. Physical Therapy 2007

Clinical Prediction Rule for Neck Pain Age- 18-60 Neck pain with and without unilateral arm symptoms NDI > 10% Exclusions: Red flags, whiplash < 6 weeks, cervical spinal stenosis, CNS problem 2 signs of nerve root myotomes, sensation, reflexes Numeric Pain Rating NDI and FABQ Distal symptom local Various measurements Neurological Screen Postural assessment Cervical ROM Joint Mobility Strength/endurance of muscles Spurlings, Roos, Distraction, ULTT

Intervention 3 Thrust Manipulations 2 reps of each Seated Distraction

Intervention Supine Upper Thoracic Manip

Intervention Supine Middle Thoracic Manipulation

Other Intervention Cervical ROM

Outcomes Greater than +5 point change on global rating of change If not achieved after treatment 1, repeated on next treatment No +5 after 2 treatments= Non Responder