Neck Pain w/ Radiating Sxs

neck pain w/ radiating pain common sxs slide 3

UE dermatomal parethesia/numbness slide3

Neck Pain w/ Radiating Sxs; ICD 10 - Cervical Radiculopathy

Compression of spinal nerve roots as exiting IVF

Stenosis (osteophytes)

HNP

Cyst formation

DJD- boney hypertrophy - Facet/Uncinate

Neck pain w/ radiating sxs or Neck pain w/ related UE sxs (Pain that radiates or refers into parascapular region or UE (scapula into shoulder); signs & sxs

W/ or W/O neck pain/stiffness

shoulder pain, (burning, throbbing, cramping)

May or may not follow a dermatomal pattern

Numbness &/or tingling into upper quarter

Complaints weakness, Sensation Changes

Adverse Neurodynamics, DTR changes

Limitations in cervical-thoracic or UE ROM

what are things that could cause foraminal stenosis?

osteophyte formation (DJD, aka age related changes)

nuclear tissue outside of disc causing inflammation surrounding nerve root

if you're performing all types of interventions & no sxs change; may require

oral steroids and check sxs

50% of pts referred to PT for shoulder pain had

cervical component (rule out spine)

median neurodynamic test is most sensitive test (rule out) for cervical radiculopathy due to having

all the nerve roots (radial does too but not as sensitive)

nerve root for Radial Forearm pain, pain in thumb & index fingers, affected Biceps/wrist extension function, & brachioradialis reflex

C6

the nerves in the middle seem to be most affected which are in

C5-C6

what nerve root issue causes Lateral Arm Pain, deltoid motor dysfunction, and biceps reflex issue

C5

Cervical Radiculopathy Course, Acute presentations such as Acute injury of neck

Insidious onset (gradual or rapid)

Maybe Inflammatory: Inflammatory mediators may further irritate spinal nerve roots

Consistent or transient compression of nerve roots: Changes in sxs w/ positions & activity

Cervical Radiculopathy Course; sub-acute → chronic; presents as

Non-inflammatory

More commonly transient sxs that will change w/ positions & activities

Sensitization of neural structures related to compression or prior inflammation

inflammations impacts on presentation of cervical radiculopathy

it will cause a mechanical presentation

cervical radiculopathy pain phenotype

neuropathic

Cervical Radiculopathy Clinical Course; prognosis

Generally good

Presence of centralization is believed to predict a good prognosis

Natural history weeks to months

Cervical Radiculopathy Clinical Course: patient education

Pinched Nerves? Fluid dynamics explain more subtle interactions. Changes in Fluid Dynamics. Axonalplasmic flow. Change in disc hydration. If fluid line is interrupted, then it can cause sxs. Sensitization of neural structures

Referred pain versus radicular pain? referred pain wont have reflex, strength, or dermatomal changes.

if a pt has a less severe onset sxs

less likely to have resolution (linger for time w/out tx)

if a pt has a more severe onset sxs =

more likely to have resolution

Cervical Radic Differential Dx: Isolated weakness or sensation change to nerve distribution

Peripheral nerve Injury

Cervical Radiculopathy Differential Diagnosis: LE symptoms, UMN signs, UE weakness

cervical myelopathy

Cervical Radic Differential Dx: Pain or dysfunction of shoulder related to shoulder pathology

shoulder disorders

Cervical Radic Differential Dx: Condition presents most often as a traction injury such as arm pulled, cervical thoracic ROM might look fine

brachial plexopathy (Injury to the plexus (traction or compression))

Cervical Radic Differential Dx: In this condition, cervicothoracic ROM won’t be provocative, C8-T1 neurologic deficits/symptoms produced w/

TOS testing; TOS

Cervical Radic Differential Dx: Pain in shoulder & arm due to compression of brachial plexus- C8-T1- Horner's syndrome, affects dermatomal patterns, stripes around

Herpes Zoster (shingles)

Cervical Radic Differential Diagnosis: Somatic structures can refer pain from neck- Clinical exam w/o signs of nerve root compression is classified as

referred pain from neck

Cervical Radic Differential Dx: Effects distal UE, vasomotor changes, swelling, trophic changes, hyperalgesia

Sympathetic or Complex regional pain syndrome (CRPS), combo of sympathetic impairment w/ central sensitization & nocioplastic pain (affects hands & feet, sees them as foreign body, can be caused by fracture), hard time differentiating lefts & rights (use mirror therapy)

Test Cluster Procedures for cervical radiculopathy

1. Spurling’s (most Specific)

2. Neural Dynamics (Most Sensitive)

3. Cervical Distractions

4. Cervical Rotation ROM < 60 Degrees (closing of foramen)

Neurodynamics testing considered highly Sensitive for

neural entrapments: Good at ruling out CR

Low specificity for any particular neural entrapment: Not great for ruling in CR

Neurodynamics Testing AKA Upper Limb Tension Test (ULTT), Assessment can be turned into

intervention such as sliders and tensioners

Physical Therapy Management for Cervical radiculopathy

Repeated motions/MDT: Emphasis on centralization of sxs, Directional Preference

MT, Exercise

Neurodynamic Interventions: tensioners & sliders

traction: manual & mechanical

Repeated movements in the Cervical Spine: establish baselines on

Neurologic status

sx presentation

Cervical ROM: Flexion, Extension, Rotation, Side Bend/Lateral Flexion, Retraction, Protrusion

On Going Evaluative Process: mechanical changes

Changes in ROM

Ex after repeated cervical retraction- cervical rotation & extension ROM have improved

On Going Evaluative of sx changes; such as

Numbness & tingling in 2nd & 3rd digit resolve

Neck pain improves

Cervical extension Pain free ROM improves

On Going Evaluative Process: keep eye on neurologic testing

Sensation & Reflexes?

Motor in-session changes?

Grip Dynamometer

Neruodynamics?

pattern of Centralization: Shoulder blade (hip of the UE)

Reduction in symptoms from

proximal to distal; Pain, Numbness, and tingling

Mechanical Dx & Tx: Derangement category includes

Rapid Changes in pt presentation (ex sxs or Mechanical) (repeated motions)

Mechanical Diagnosis and Treatment dysfunction category

mobility deficits

Mechanical Diagnosis and Treatment postural category

movement coordination impairments (DNF training, cervical flexor endurance)

Mechanical Dx & Tx: other category is

specific pathology (chronic pain syndrome, stenosis, post op)

for cervical traction, look for

ears over shoulders (double chin)

Loading progressions for retraction, seated

retraction → retraction w/ pt overpressure (push on own chin) → retraction w/ PT overpressure

retraction Loading progressions in supine

retraction on pillow → retraction w/ head off the end of table (pt or PT support) → retraction w/ PT overpressure

What light is it when you see symptomatic or mechanical improvements in symptoms

Green Light → Continue w/ current intervention

What light is it when MDT may ↑ or ↓ sxs during repeated mvmts. No better but also no worse after mvmts

Ex: Repeated Cervical Retraction

Neck pain is a little worse arm pain is better during cervical retraction

Not better after

Progress to retraction w/ pt over pressure

Yellow Light --> increase forces or change positions

What light is it when sxs or mechanics are worse after intervention

ex Arm pain is worse w/ cervical retraction in seated

Red Light → Change positions or direction (Progress to cervical retraction in supine)

Repeated movements in the cervical spine may help w/ sx management during the

early stages of rehab

Repeated movements in cervical spine may work best when included in multimodal treatment approach including

MT for symptom modulation: Centralization of sxs

MT & ther ex to address cervical thoracic mobility

Exercise for cervico-scapular-thoracic strength & endurance

MT for cervical radic: Thoracic Mobilization Manipulation mechanisms

Non-specific effects/contextual; Neurophysiologic mechanisms

Upper thoracic mobility may directly limit cervical ROM, Limitations in thoracic mobility may ↑ stress to C-Spine

Mechanical Traction initial prescription

Intermittent: 60 seconds on 20 seconds off

12 lbs of force

Relaxation force 50%

May ↑ forces & hold times based on pt response & tolerance: ↑ traction may help to better alleviate sxs, Too much traction force may cause latent neck pain

Traction Contraindications

Jt hypermobility or instability

Acute injury/inflammation

Peripheralization of sxs w/ traction

Malignancy

infection (such as osteomyelitis or diskitis)

Severe osteoporosis, Inflammatory arthritis

Fracture, pregnancy

Cord compression

Uncontrolled hypertension, CVD, carotid, or vertebral artery disease

exercises for cervical radiculopathy

Cervical Thoracic Mobility exercises

DNF Endurance Training

Craniocervical Flexion

Neck extensor training

Scapulothoracic training

Patient education for cervical radiculopathy

Prognostic Factors/natural hx: likely to get better will take time

nature of neurogenic/pathic pain: Tissue irritability vs tissue harm, Pain science, when to protect & when to push

activity modification: gradual return to regular exercise/activity