neck pain with movement coordination deficits

what are the red flags to consider here?

fracture, upper cervical ligamentous instability, vascular concerns

what rules do we utilize to helps us rule out the need for imaging after a trauma?

canadian C spine rules

who can we use the canadian C spine rules. for?

• must be 16 years or older

• alert and oriented (Glasgow score 15 or greater)

• stable vital signs

• no known cervical surgery

*they have a sensitivity and we can be confident that a fracture will not be missed 95% of the time

step 1 of the canadian C spine rules is to assess for high risk factors mandating radiographs. what are these factors and what do we do if any of them are positive?

Age >65 years old OR dangerous MOI OR parasthesia in UE

*if positive, refer out for an open mouth X ray

what are considered dangerous MOIs?

1. fall from 3 feet or 5+ stairs

2. axila load to head (diving)

3. high speed MVC (>62 mph)

4. rollover MVC

5. MVC with ejection

6. motorcycle, vespa, electric bike crash

7. bicycle crash

step 2 of the canadian C spine rules is to assess for low risk factors to allow for safe examination. what are these factors and what do we do if any of them are positive?

1. simple rear end MVC or

2. sitting position in ED or

3. ambulatory at any time or

4. delayed onset of neck pain or

5. absence of midline tenderness

*if any are present, continue with an exam, FIRST assessing cervical rotation >/= 45 degrees to assess the AA joint

what do we do if cervical rotation >/= 45 degrees when assessing for a fracture?

if yes, proceed with further examination

if no, stop and refer for x ray

discuss odontoid fractures

they make up 10-20% of cervical spine injuries and are the most common c spine fracture in individuals >65 with a rate growing faster than any other spine fracture

what are associated issues with odontoid fracture and why?

decreased QoL, increased mortality rates, and increased burden on the heatlthcare system due to the odontoid not having good blood flow so healing time increases

what syndromes fit into this category?

whiplash associated disorders

neck strain or sprain

subacute or chronic neck pain

what are the subjective exam findings for a neck sprain, subacute or chronic neck pain?

• result of poor posture, poor ergonimics, or poor movement coordination

• minor to moderate trauma, such as MVA

• longstanding neck pain (duration >12 weeks)

• sensations of muscle tightness or spasms

• intolerance to prolonged static postures

• fatigue and inability to hold head up (often later on in evening)

• better with external support, including hands or collar

• frequent need for self manipulation

• ergonimic inefficiencies with performing repetitive activities

what are the subjective exam findings for whiplash?

• history of trauma

• associated (referred) shoulder girdle or upper extremity pain

• nonspecific concussive signs and symptoms— dizziness/nausea, headache/concentration/memory difficulties, confusion, hypersenitivity to stimuli, heightened affective distress

what do the grade of whiplash mean?

worst grade= worst injury and worst symptoms

what are the risk factors for developing whiplash associated disorder?

• neck pain prior to collision

• being the driver or the front seat passenger

• being exposed to a rear end collission or frontal collision rather than a side collision

• female gender

• seveirty of the crash

what are the outcome measures used here?

• FABQ and Tampa scale of kinesiophobia

• pain catastrophizing scale: score >30

• Impact of event scale- Revised (IES-R): this ID’s post traumataic stress with the higher the score (>24), the higher the concern for PTSD

what is the prognosis for recovery?

• 45% have a quick and easy recovery with initial milder pain/disability but full recovery in 6-12 weeks

• 39% have initial moderate pain/disability with recovery to mild levels

• 16% have initial severe levels of pain/disability persisting at chronic to moderate to severe levels for the 12 month study period

what are crash related factors that are not predictive of poor recovery?

head position at impact, use of head restraints, direction of impact, airbag deployment

what are crash related factors that are predictive of poor recovery and what does it indicate?

self rated collision severity which is subjective and tells us the perception of symptoms and of the trauma plays a major role in recovery

what is the key question to asks patients that has been found to be a predictor of their prognosis?

do you think you are going to get better soon?

what are factors predictive of a poor recovery and what outcome measure/assessment can we use to determine them?

1. high initial pain: VAS/NPRS

2. high initial disability: NDI >40

3. PTSD symptoms: IES-R Hyperarousa >/=6

4. negative expectation of recovery: subjective questioning

5. greater CROM limitations: CROM testing

6. cold hyperalgesia: pressure algometry

what are objective exam findings?

• negative neuro screen

• cervical CROM is worst in mid ranges

• palpation of the myofascial trigger points reproduces symptoms

• CPAs or UPAs may reproduce symptoms in the neck or referred shoulder girdle symptoms

• strength and endurance deficits of the neck and scapular muscles

• positive pressure algometry— they will have decreased pain pressure threshold

• positive craniocervical flexion test or neck flexor endurance test

• altered muscle activation patterns, proprioceptive deficits, postural balance or control

what are the values for the neck flexor endurance test?

for patient without neck pain, normal is 39 seconds. patients with neck pain, normal is 24 seconds

what are the signs of concussion?

• fatigue

• dizziness

• decreased concentration

• irritability

• psychomotor slowing

• memory problems

• insomnia

• anxiety

• personality changes

what are the parts that make up the vestibular system?

inner ear and connections to the brainstem, cerebellum, cortex, ocular system, and postural muscles

what are the functional units of the vestibular system?

1. vestibulo-ocular reflex: provides visual stability during head movement

2. vestibulospinal system: provides postural control

what are the parts of the VOMS used to test for concussions?

• smooth pursuits: ability to follow a slowly moving target

• saccades: ability of eyes to move quickly between targets— horizontal and verticle

• convergence: ability to view a near target without double vision

• vestibular ocular reflex (VOR) test: ability to stabilize vision as the head moves

• visual motor sensitivity (VMS) test: ability to inhibit vestibular induced eye movements using vision