physical therapy protocols for neck region

Red Flags for Potential Serious Conditions in Patients with Head and Neck Problems

Red Flags for the Head and Neck Region

Condition Red Flag

Data obtained during Interview/History

Red Flag Data obtained during

Physical Exam Subarachnoid Hemorrhage – Ischemic Stroke1,2

Sudden onset of a severe headache History of hypertension

Concurrent elevated blood pressure Trunk and extremity weakness, Aphasia Altered mental status Vertigo, Vomiting

Vertebrobasilar Insufficiency3-5

Dizziness Headaches Nausea Loss of consciousness

Vertigo that lasts for minutes (not seconds) Visual disturbances Apprehension with end range neck movements Unilateral hearing loss Vestibular function abnormalities

Meningitis6,7 Headache Fever Gastrointestinal signs of vomiting and

symptoms of nausea

Positive slump sign Photophobia Confusion Seizures Sleepiness

Primary Brain Tumor8-11

Headache Gastrointestinal signs of vomiting and

symptoms of nausea

Ataxia Speech deficits Sensory abnormalities Visual changes Altered mental status Seizures

Mild Traumatic Brain Injury – Post Concussion Syndrome – Subdural Hematoma12,13

Dangerous injury mechanism Headache Nausea/vomiting Sensitivity to light and sounds

Loss of consciousness/dazed – an initial Glaslow Coma Scale of 13 to 15

Deficits in short term memory Physical evidence of trauma above the clavicles Drug or alcohol intoxication Seizures

References: 1. Hiroki O, Hidefumi T, Suzuki S, Islam S. Risk factors for aneurysmal subarachnoid hemorrhage in Aomori, Japan. Stroke.

2003;34:34-100. 2. Hong YH, Lee YS, Park S. Headache as a predictive factor of severe systolic hypertension in acute ischemic stroke. Can J

Neurol Sci. 2003;30:210-214. 3. Grad A, Baloh RW. Vertigo of vascular origin. clinical and electronystagmographic features in 84 cases. Arch Neurology.

46:281-4, 1989. 4. Szirmai A. Evidences of vascular origin of cochleovestibular dysfunction. Acta Neurol Scand. 2001;104:68-71. 5. Silbert PT, Bahram M, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery

dissections. Neurology. 1995;45:1517-1522. 6. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: a systematic review of the

literature. Spine. 1996;21:1746-1760. 7. Bruce, M, Rosenstein N, Capparella J, et al. Risk factors for meningococcal disease in college students. JAMA. 2001;286:

688-693. 8. Berger JP. Buclin T. Haller E, et al. Does this adult patient have acute meningitis? JAMA. 1999;282:175-181. 9. Snyder H, Robinson K Shah D, et al. Signs and symptoms of patients with brain tumors presenting in the emergency

department. J Emerg Med. 1993;11:253-258. 10. Zaki A. Patterns of presentation in brain tumors in the United States. J Surg Oncology 1993; 53:110-112. 11. Forsyth PA, Posner JB. Headaches in patients with brain tumors: A study of 111 patients. Neurology. 1993; 43:1678-1683. 12. Sobri M, Lamont AC, Alias NA, Win MN. Red flags in patients presenting with headache: clinical indication for

neuroimaging. Brit J Radiology 2003; 76:532-535. 13. Borg J, Holm L, Cassidy JD, et al. Diagnostic procedures in mild traumatic brain injury: results of the WHO Collaborating

Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004; Suppl. 43: 61-75.

Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

HEAD AND NECK SCREENING QUESTIONNAIRE NAME: __________________________________________ DATE: _____________ Medical Record #: _________________________

Yes No

1. Are you currently being treated for high blood pressure?

2. Have you recently had difficulty with speaking?

3. Have you noticed an increased clumsiness or weakness in your arms or

legs?

4. Do you frequently have headaches?

5. Have you noticed a recent decreased ability of concentrate?

6. Do you experience dizziness?

7. Have you noticed a recent change in your vision or ability to see?

8. Have you recently experienced a blow to the head or a whiplash injury?

9. Have you been experiencing nausea and/or vomiting?

10. Do you currently have a fever, or have you had a fever recently?

11. Have you recently been living in close quarters, such as in a dormitory?

12. Do you have a depressed immune system?

13. Are your eyes sensitivity to light?

14. Have you recently had a seizure?

Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

Cervical Spine Mobility Deficits ICD-9-CM code: 723.1 Cervicalgia ICF codes: Activities and Participation Domain code: d4108 Changing a basic

body position, other specified - specified as: rotating the head and neck, such as in looking to the left or to the right

Body Structure code: s76000 Cervical vertebral column Body Functions code: b7101 Mobility of several joints

Common Historical Findings:

Neck pain, usually unilateral, pain referral from base of occiput to scapular region (location of pain referral is dependent upon which segment or segments are involved)

Strain; awkward, unguarded movement; or prolonged period of time in strained position ("Woke up with pain")

Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:

Increase in pain at end range of rotation left or rotation right Symptoms reproduced with palpation of the involved facet Motion limitation and pain at end range of either anterior/superior glide or

posterior/inferior glide of the involved spinal segment Physical Examination Procedures:

Cervical Accessory Movement Test Anterior/Superior Glide

Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency 1

Cervical Accessory Movement Test

Anterior/Superior Glide Performance Cues: Use DIP, PIP, or MCP for contact Use a "Flat Hand" - whole palm contacting side of neck and head Slowly and predictably sink through the skin and myofascia until contact with "articular

pillars" is made Pull the top half of the "pea-sized" facet "toward the eyes" (ok to facilitate rotation to the

opposite side of facet being assessed) Assess mobility, resistance to movement, and symptom response of C2-3, C3-4, C4-5,

C5-6, and C6-7

Cervical Accessory Movement Test

Posterior/Inferior Glide Performance Cues: Use PIP or MCP contact; flat, soft hand; predictable, uniform movement; sink through

soft tissue


Push the top half of the facet down and back (ok to facilitate side bending to same side of facet being assessed)

Assess mobility, resistance, and symptom response of each segment

Cervical Spine Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term

“Cervical Facet Syndrome” Description: Dysfunction of the movement of the one vertebrae of the cervical spine relative to its adjacent vertebrae. This is usually a result of muscle imbalances, facet irregularities or trauma. Patients with this condition commonly complain of unilateral neck and upper back pain that increases at the end ranges of left or right sidebending or rotation. And, repeated flexion and extension movements do not improve or worsen the patient’s baseline level of pain Etiology: The cause of this dysfunction is believed to be a movement abnormality where a segment of the spine is unable to either flex, extend, side bend or rotate normally in a pain free manner on its adjacent vertebrae. This movement abnormality can be caused by either a displacement of fibro-fatty tissue within the outer borders of the facet capsule or posttraumatic fibrosis of the facet capsule. The cause of the movement abnormalities and the associated pain is thought to be a sudden, awkward, twisting or bending motion. This results in a potentially reversible displacement of fibro-fatty tissue. The cause could also be a mild joint contracture following the fibrotic healing of a posttraumatic facet capsule. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7101.3 SEVERE impairment of mobility of several joints

• Unilateral posterior-to-anterior pressures at the involved segment reproduce the patient’s pain complaint

• Motion restrictions are present at the involved segment • Myofascia associated with the involved segment is usually hypertonic and painful

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7101.2 MODERATE impairment of mobility of several joints As above with the following differences: • The patient’s unilateral symptoms are reproduced only with overpressures at end

ranges of left or right sidebending Note: Improved segmental mobility is commonly associated with improving

symptomatology Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7101.1 MILD impairment of mobility of several joints As above with the following differences:


• The patient’s unilateral symptoms are reproduced only with end range overpressures in either a combined extension and sidebending motion or a combined flexion and sidebending motion

Now when the patient is less acute examine for muscle flexibility and strength deficits that may be a predisposing factor for future injury. For example:

• Muscles that commonly exhibit flexibility deficits in patients with facet abnormalities

are middle and posterior scaleni, SCM, upper trapezius, and the myofascia associated with the involved cervical segment

• Muscles that are commonly weak are the cervical neck flexors (i.e., longus colli),

upper thoracic extensors and scapular retractors/adductors (i.e, middle and lower trapezius)

Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Restore painfree active spinal mobility

• Physical Agents Ice (or heat) to provide pain relief and reduce muscle guarding

• Manual Therapy

Soft tissue mobilization to the myofascia associated with the involved cervical segment

Isometric mobilization and contract/relax procedures to the involved segment to reduce muscle guarding

Passive stretching procedures to restore normal cervical segmental mobility

• Therapeutic Exercises Instruction in exercise and functional movements to maintain the improvements in

mobility gained with the soft tissue and joint manipulations Strengthening exercises for the neck flexors


• Re-injury Prevention Instruction

Instruct the patient in efficient, painfree, motor performance of movements that are related by the patient to be the cause of the current episode of neck pain

Sub Acute Stage / Moderate Condition: Goal: Restore normal, painfree response to overpressures at end ranges of cervical rotation and

sidebending

• Approaches / Strategies listed above – focusing on:

• Manual Therapy Soft tissue mobilization and joint mobilization/manipulation to normalize the segmental mobility

Note: Performing upper cervical joint mobilization/manipulations with the patients upper cervical spine at end ranges of extension or the end ranges of combined of extension/rotation movements is contraindicated due the potential disastrous effects that these manipulative procedures have been reported to have on some individual’s vertebral artery. Thus, all upper cervical manipulations are performed with the head and neck in the neutral or flexed position

• Therapeutic Exercises

Instruction in exercise and functional movements to maintain the improvements in mobility gained with the soft tissue and joint manipulations (e.g., towel SNAGs)

Settled Stage / Mild Condition: Goals: Restore normal, pain free responses to overpressures of combined extension and sidebending/rotation and/or combined flexion and sidebending/rotation

Normalize cervical and upper thoracic flexibility and strength deficits

• Approaches / Strategies listed above

• Therapeutic Exercises Stretching exercises to address the patient’s specific muscle flexibility deficits Strengthening exercises to address the patient’s specific muscle strength deficits


Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities


• Therapeutic Exercises Encourage participation in regular low stress aerobic activities as a means to improve fitness, muscle strength and prevent recurrences

• Ergonomic Instruction

Provide body mechanics instructions and modify work area as indicated to prevent symptoms. This typically emphasizes neutral cervical position for sitting, driving, traveling as a passenger in a car, bus, or airplane, reading, eating, and resting/sleeping.

Selected References Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Phys Ther. 1999;79:50-65. Jackson RP. The facet syndrome: myth or reality? Clin Orthop Rel Res. June, 1992. Taimela S, Takala E, Asklof T, Seppala K, Parvianen S. Active treatment of chronic neck pain. a prospective randomized intervention. Spine. 2000;25:1021-1027. Jull G, Trott P, Potter H, Zito G, Niere K. Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002;27:1835-1843.


Posterior Cervical Myofascia

Soft Tissue Mobilization

Suboccipital Myofascia Soft Tissue Mobilization


Impairment: Limited and Painful Cervical Flexion, Right Rotation or Right Sidebending

Cervical NAG Cues: Hug the patient’s head with your right forearm and anterior lateral trunk

It usually helps to be in front of the patient’s shoulder The 5th finger of right hand is the “dummy” finger positioned on the spinous process or

articular pillar Provide traction or other combined movements by weight shifting to the backward (right)

leg Mobilize in the direction of the facet plane (superiorly more than anteriorly) using the left lateral

wrist/thenar eminence to provide the force Generate the superior-anterior glide using left elbow flexion “Catch” the skin with the “dummy” finger a segment of two below the involved If the procedure is painful, stop. Consider naging in a slight different treatment plane or

on a different cervical segment The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 12-15, 1995


Impairment: Limited and Painful Cervical Right Rotation

Cervical SNAG Cues: Use the right thumb as the “dummy” thumb over either the spinous process or the

articular pillar The left thumb provides the SNAG Sustain the NAG pressure in the plane of the facet – think superiorly more than anteriorly Remember: 1) NAG, 2) Sustain the NAG, 3) Overpressure end range, 4) Sustain the NAG during

left rotation back to neutral, 5) Release NAG Use the ulnar aspect of the left hand or little finger, if possible, to limit thorax right rotation by

manually cuing the anterior aspect of the left clavicle Remember: A SNAG is indicated if it permits (and improves) painfree motion Alteration of the direction of the active cervical motion while performing this SNAG can also be

used to treat limited and painful cervical sidebending, extension, or flexion The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 18-25, 1995


Impairment: Limited Cervical Segmental Sidebending/Rotation

Cervical Superior/Anterior Glide

Cues: Contact the articular pillar of the superior vertebrae of the involved segment and glide it “toward the eyes”

Stabilize the vertebrae below by contacting its spinous process (i.e., stablize the right side of the spinous process of C6 with the left middle finger as the right middle finger contacts the posterior aspect of the right C5 articular pillar and provides a superior/anterior glide of C5)

Utilize this procedure to address both the segmental myofascia and joint mobility deficits The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 260, 1993 Impairment: Limited Cervical Segmental Rotation

Cervical Rotation in Neutral Cues: Assess the amplitude (and end feel) of cervical rotation (using an anterior/superior glide)

of the involved segment in neutral Add combined movements of cervical sidebending, side gliding, slight anterior (or

posterior) gliding, slight extension (or flexion), traction, and compression (firm “hug” of the head and neck), until the anterior/superior glide motion barrier (i.e., end feel) is as “crisp” as possible

Mobilize (or manipulate) with a low amplitude force into this barrier The following reference provides additional information regarding this procedure: Laurie Hartman DO: Handbook of Osteopathic Technique, p. 171-172, 1997


Impairment: Limited Cervical Segmental Flexion, Right Sidebending, and Right Rotation

Cervical Spine Contract/Relax (of segmental extensors and left sidebenders)

Cues: “Slump the cervical spine as best as possible to create the maximal available posterior

translation of the involved segment Maintaining the posterior “slump”, translate the involved segment to the left to obtain the

maximal available lateral translation The intention is to create an apex of both posterior translation and left lateral translation

at the involved segment, thus, placing the involved facet capsule and its associated segmental myofascia at end range

Elicit contraction of the left sidebenders and/or left extensors – relax – take up slack – repeat

Use a soft and “flat” manual contact to avoid painful pressure with the right hand Utilize “traction” with the left hand to enhance the sidebending stretch to the left facet

joints and myofascia The following references provides additional information regarding this procedure: John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 260, 1992 Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 191, 1996


Impairment: Limited Cervical Segmental Flexion, Right Sidebending, and Right Rotation

Cervical Right Sidebending/Rotation in Flexion Cues: At the end range of both posterior and lateral translation barriers - apply low amplitude

mobilizations or a low amplitude manipulation into the barrier The direction of the mobilization force is laterally (“to open the joint on the opposite

side”) Comfort and effectiveness is increased if: 1) the right hand maintains a broad surface

contact, and 2) the left hand applies a “traction” force to maintain the stretch to the left cervical facets and segmental myofascia

The following reference provides additional information regarding this procedure: Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 197, 199


Impairment: Limited Cervical Segmental Extension, Right Sidebending, and Right Rotation

Cervical Spine Contract/Relax

(of segmental flexors and left sidebenders) Cues: Use the index finger of the right hand to anterior glide, then, left laterally translate the

involved segment Elicit contraction of the left sidebenders and/or flexors of the involved segment - relax –

take up slack in both “barriers” – repeat

The following references provides additional information regarding this procedure: John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 257-

259, 1992 Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 189-190, 1996

Cervical Sidebending/Rotation in Extension

Cues: At the end range of both anterior and lateral translation barriers - apply low amplitude

mobilizations or a low amplitude manipulation into the barrier The direction of the mobilizing is primarily inferiorly (“to close the joint on the same side”)

The following references provides additional information regarding this procedure: John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p.261, 1992 Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 196, 1996


Impairment: Limited C1/C2 Right Rotation

C1/C2 Contract/Relax Cues: Fully flex C2 through C7

Adding flexion at the occiput/C1/C2 areas assists in preventing rotation past C2 (i.e., it helps create a “firm” C1/C2 rotation barrier)

Rotate occiput and C1 to the right until the first “barrier” - be sure to 1) maintain the cervical flexion, and 2) prevent cervical sidebending

“Look with your eyes to the left” – Relax – Take up the now available right rotation slack passively (or “gently look to the right”) - relax - repeat contract/relax procedures 3 to 5 times


264, 1992 Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 192, 1996



C1/C2 Rotation Cues: Stabilize the right lamina of C2 with your left thumb

Comfortably hug the patient’s head and rotate it (with C1) to the right Tilt the head to the left to allow some slack in the left alar ligament Apply a passive stretch (or, a contract/relax stretch) Be especially tuned into the patient with regards to VBI symptoms or signs while

performing this technique The following reference provides additional information regarding a similar procedure: Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 279, 1995


Impairment: Limited Occiput/C1 flexion Limited Occipital Posterior Glide (or C1 Anterior Glide) on the Left

Occipital Posterior Glide Cues: Rest the right middle finger on the left thenar eminence

Position the patient (and your hands) so that the left lateral mass of C1 is contacted by the “dummy” middle finger

Apply a posterior glide to the left occipital condyle via a posterior force on the patients left forehead (using flexion of your thorax – with your left anterior deltoid/clavipectoral area contacting the patient’s left forehead)

C1 Anterior Glide


Impairment: Limited Upper Cervical Right Sidebending Limited C1 Right Lateral Translation

C1 Lateral Translation Cue: Contact the left C1 lateral mass with 1) your left index or middle finger, or 2) the radial

side of your left index finger MCP area Stabilize the skull with your right hand Apply right lateral translatory oscillations or stretching forces to C1 Be kind and gentle - but effective Don’t be in a hurry

The following reference provides additional information regarding similar procedures: Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 243, 277,

1993


Impairment: Limited Occipital Flexion and Right Sidebending

Occiput/C1 Contract/Relax (of segmental extensors and left sidebenders)

Cue: Nod the occiput to take up the flexion barrier

Translate the nodded occiput to the left to first upper cervical barrier – not mid cervical barrier

Keep the eyebrows parallel to the transverse plane when translating the occiput (to avoid inadvertent left sidebending)

Elicited contraction of the segmental extensors (“look to the left”) Manually cue either the anterior aspect of the chin or the left zygoma (with your left

forearm) when providing the verbal commands Maintain both the flexion and the left translation barriers during the contraction Relax Take up available slack in both barriers Repeat


268, 1992 Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 194, 1996



Occipital Distraction in Flexion and Sidebending Cues: Contact the right occipital condyle with the anterior surface of the index finger

metacarpal of the right hand As best as possible, align your right forearm parallel to the distraction force direction “Hug” the right side of patient’s head with your left forearm Position the patient at the barriers of both flexion and left translation - as he/she exhales The distraction mobilization or manipulation force primarily comes from your index

finger metacarpal – using a weight shift from your trunk If you are not moving the patient’s feet (“positive toe sign”) you are probably not

providing enough traction force to distract the patient’s occiput from C1




Impairment: Limited Occipital Extension and Right Sidebending

Occiput /C1 Contract/Relax (of segmental flexors and left sidebenders)

Cues: Extend the head (not the cervical spine) to take up the extension barrier

Translate the extended head to the left to the first (upper cervical - not mid cervical) barrier Translate left - not sidebend left Elicit contraction of the segmental flexors (“look down toward your feet”) or sidebenders

(“look to the left) Manually cue either under the chin or the left zygoma when providing the verbal

commands Maintain both barriers during the contraction Relax - take up slack – repeat

The following references provides additional information regarding this procedure: John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p. 266, 1992 Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 193-194, 1996

Occipital Distraction in Extension and Sidebending

Cues: Contacts and force application is similar to the occipital distraction in flexion Position the patient at the barriers of occipital extension (not cervical extension) and left

translation - as he/she exhales Maintain these barriers – apply the distraction mobilizations or manipulation

The following references provides additional information regarding this procedure: John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p.268, 1992 Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 201, 1996


Cervical Spine Movement Coordination Deficits ICD-9-CM code: 847.0 Neck ligament sprain ICF codes: Activities and Participation Domain code: d4159 Maintaining a body position,

unspecified Body Structure code: s76000 Cervical vertebral column Body Functions code: b7601 Control of complex voluntary movements


Significant trauma (e.g., MVA, fall, blow to head) Muscle “tightness” or “spasm”


Pain with mid-range motions - increases at end range of painful motion Tender with palpation of area (ligamentum nuche, spinous process and interspinous

space) of the involved segment(s) Pain with central posterior-to-anterior PA pressures If upper cervical ligament strain: laxity and/or symptom alteration with ligaments

stability exam Physical Examination Procedures:

Palpation of Midline Soft Tissue

Central Posterior-to-Anterior Pressures

Performance Cues: May need to slightly flex head and neck to differentiate segments Support head and neck to limit muscular contraction Palpate areas near ligamentum nuche, spinous processes, and interspinous spaces –

determine symptom response


Alar Ligament Integrity Test Alar Ligament Integrity Test

Performance Cues: Keep head supported to limit muscle guarding Place head and neck in midline Pinch C2 spinous between left thumb and index finger Side bend skull 10-15 degrees to the right Normal - lateral aspect of the C2 spinous immediately moves into thumb Abnormal - the C2 spinous process does not move or the movement is noticeably delayed

as the head is sidebent Involuntary or voluntary muscle guarding may produce false negative results to these

examination procedures

Sharp-Purser Test for Ligamentus

Integrity for the Transverse Ligament Performance Cues: Flex skull slightly while sitting - about 25 degree or until the motion is “taken up” - do not take

up slack in tissues below C2. In the abnormal - head flexion allows the occiput and C1 vertebrae to translate anteriorly

relative to C2. Thus, this position may provoke symptoms. Posteriorly translate the skull-with the head in slight flexion - while stabilizing the spinous

process of C2 with an anteriorly directed force In the abnormal - relative posterior translation of the skull in noted (approximately 5mm).This

position may alleviate the patient’s symptoms In the normal - no symptoms are produced with head flexion and no translatory motion is

detected with occiput/C1 (posteriorly directed) translation (while C2 is stabilized) The stabilization (anteriorly directed) force of C2 is firm


Cervical Spine Stability Deficits: Description, Etiology, Stages, and Intervention StrategiesThe below description is consistent with descriptions of clinical patterns associated with the vernacular term

“Cervical Instability or Cervical Ligament Strain” Description: A sudden jerky movement, “whiplash” to the neck, or blow to the head could lead to cervical ligament sprain. Pain is usually felt in the back of the neck that gets worse with movement. Muscle spasms and pain are the common complaint. The pain may be referred to the upper back, shoulder girdle or upper extremity. The pain may be more noticable a day after the injury. The pain symptoms worsen with movement. Headaches, increased fatigue, irritability, and restless sleep are also associated with this disorder. Etiology: The cause of this disorder could be due to significant trauma such as car crash, or applying sudden brakes in which the head goes backward while the body stays back due to the seat belt. This causes head and neck to extend and get overstretched causing stress on the ligaments of the neck. Contact sports are also a common cause of cervical ligament sprains. Individuals with a long history of a collagen vascular disease, such as rheumatoid arthritis, may have upper cervical ligamentous instability as an unfortunate consequence of their disease.

Physical Examinations Findings (Key Impairments)

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7601.3 SEVERE impairment of motor control/coordination

of complex voluntary movements • Pain with end range cervical motion • May have swelling or bruising at the injury site • Muscle spasms at the associated spinal segment • Central or unilateral posterior-to-anterior pressures reproduce the reported symptoms • May exhibit laxity with ligamentous integrity tests (e.g., alar ligament integrity test or

the Sharp-Purser test) Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7601.2 MODERATE impairment of motor control/coordination of complex voluntary movements

• As above – the severity of the tenderness and muscle guarding may resolve at a slow rate if the injury was significant.

• Be cautious of an underlying instability that is potentially dangerous to the patient’s neural structures. Muscle guarding at the segment may mask this instability.

• Weakness of neck musculature, especially the neck flexors Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7601.1 MILD impairment of motor control/coordination of complex voluntary movements

As above with the following differences:


• Symptoms worsen or peripheralize with sustained end range positions or with repeated movements into the patient’s available range

Intervention Approaches / Strategies

Acute Stage / Severe Condition Goals: Allievate pain while in neutral cervical positions

Prevent further stress on injured tissues

• Re-injury Prevention Instruction Limit active and passive movement to painfree ranges Instruction is proper neutral positions for common activities such as sleeping,

sitting, reading, driving, and eating, as well as for movements such as moving from supine to a sitting position

• External Devices (Taping/Splinting/Orthotics)

A rigid cervical collar is often indicated for acute cervical sprains to limit further stress on the damaged tissues

A soft cervical collar may be useful in less severe strains to cue the patient to maintain the neutral position

• Physical Agents

Ice packs applied with the neck in a neutral position may by applied for 15-30 minutes every few hours to reduce pain and inflammation

Sub Acute Stage / Moderate Condition Goals: Prevent re-injury

Strengthening of neck musculature to improve dynamic stability Improve mobility in areas superior or inferior to the injured, hypermobile segment



Initiate cervical stabilization/strengthening program – with emphasis on the deep cervical neck flexors (i.e., longus colli)

• Manual Therapy

Soft tissue and joint mobilization to restricted segments in the upper thoracic, mid-cervical, or upper cervical region. Caution not to mobilize any segment that is potentially hypermobile or unstable.

• Ergonomic Instruction

Promote efficient, painfree, motor control of the neck, scapulae and arm Modify activities to prevent overuse and re-injury


Modify workstation to reduce risk of mounting pressure on the neck

• Re-injury Prevention Instruction Emphasize the importance of neutral posture Emphasize the importance of maintaining adequate stabilization through muscular

control of the unstable segment – especially in individuals who participate in contact sports or other activities involving potential stress to the cervical spine.

Settled Stage / Mild Condition Goal: Progress activity tolerance

• Approaches/ Strategies listed above

• Therapeutic Exercises Provide endurance training to maximize muscle performance of the neck,

scapulae, and shoulder girdle muscles required to perform the desired occupational or recreational activities

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities


• Ergonomic Instruction Add job/sport specific training

Selected References Donatelli, Robert. Orthopedic Physical Therapy. Georgia: Churchhill Livingstone Inc. 1994. Gennis P, Miller L, Gallagher J, et al: The effect of soft cervical collars on persistent neck pain in patients with whiplash injury. Acad Emerg Med 3:568-573, 1996. Magee, David. Orthopedic Physical Assessment. Pennsylvania: W.B. Saunders Co. 1997. Meadows J: The Role of Mobilization and Manipulation in treatment of Spinal Instability. J Orthop Phys Ther Clin N Am 8:519-34, 1999. O’Grady WH, Tollan MF: The role of exercise in the treatment of instabilities of hypermobilities in the cervical spine. Orthop Phys Ther Clin N Am 10:3, 475-501, 2001. Swinkles-RAH, Oostendorp-RAB: Upper cervical instability: fact or fiction? Journal of Manipulative and Physiological Therapeutics 19:185-94, 1996.


Neck and Headache Pain ICD-9-CM code: 723.2 cervicocranial syndrome ICF codes: Activities and Participation Domain code: d4158 Maintaining a body position,

other specified - specified as: maintaining the head in a flexed position, such as when reading a book; or, maintaining the head in an extended position, such as when looking up at a computer screen or video monitor

Body Structure codes: s7103 Joints of head and neck region Body Functions code: b28010 Pain in head and neck


Unilateral neck pain with referral to occipital, temporal, parietal, frontal or orbital areas Headache precipitated or aggravated by neck movements or sustained positions Noncontinuous headaches (usually < 1 episode/day; < 2 episodes/week)


Observable postural asymmetry of the head on neck (sidebent or extended) Headache reproduced with provocation of the involved segmental myofascia and/or joints O/C1, C1/C2, or C2/C3 restricted accessory motions with associated myofascial trigger

points Physical Examination Procedures:

Palpation/Provocation of Suboccipital Myofascia


O/C1, C1/C2, or C2/C3 accessory motion testing using posterior-to-anterior pressures

0/C1 accessory motion testing using C1 lateral translatoty pressures

C1 – C2 Rotation ROM testing with the C2 – C7 segments in flexion


Neck and Headache Pain: Description, Etiology, Stages, and Intervention Strategies

The below description is consistent with descriptions of clinical patterns associated with the term “Cervicogenic Headache.”

Description: Cervicogenic headache is a headache where the source of the ache is from a structure in the cervical spine, such as a cervical facet, muscle, ligament, or dura. The pain is referred to the occipital, temporal, parietal, frontal, and orbital areas. The characteristics of cervicogenic headache are unilateral dominant side-consistent headache associated with neck pain and aggravated by neck postures or movement, limited range of motion in the cervical spine and joint tenderness in at least one of the upper three cervical joints as detected by manual palpation. The aching is moderate-severe, without throbbing or lancinating pain, usually starting in the neck. The episodes can be of varying duration (few hours to a few weeks). The initial phase of cervicogenic headache is usually frequent and episodic. The occurrence among females is twice that of males. Etiology: The headache is due to a musculoskeletal disorder in the upper cervical spine. Thus, movement stresses of the upper cervical spine are associated with the headache complaint (e.g., headache is worse at the end of a days work at a computer screen or talking on the phone). Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b28010.3 SEVERE pain in head and neck joints

• Abnormal head on neck posture is commonly observed (e.g., the head is held in an excessively extended position or an excessive sidebent position relative to the upper cervical segments)

• Limited O-C1 and/or C1-C2 and/or C2-C3 segmental mobility • Headache aggravated with certain head positions or sustained movements • Headaches reproduced with provocation of the involved segment at O/C1, C1/C2, C2/C3

or with provocation of trigger points in the suboccipital myofascial or during slump testing of the dural elements

• Deep cervical flexor muscle control deficits (i.e., rectus capitus anterior and longus colli) Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b2801.2 MODERAT pain in head and neck joints

• As above – the ability to reproduce the patient’s headache via palpatory provocation of the involved joints or myofascial lessens as the mobility of the involved upper cervical segments

Settled / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b2801.1 MILD pain in head and neck joints

Now when the patient is less acute examine for ergonomic factors, postural habits, muscle flexibility and strength deficits that may be predisposing factors for upper cervical somatic disorders. For example:


• Ergonomic or postural paterns that involve excessive thoracic kyphosis and associated

excessive cervical lordosis predisposes the head to be excessively extended on the neck – placing the upper cervical extensors on a chronically shortened position – thus, precipitating the above listed impairments.

• Upper quarter muscle imbalances such as tightness of the scapular elevators (i.e., levator scapulae and upper trapezius) muscles and weakness of the scapular adductors/stabilizing (i.e., lower and middle trapezius) muscles

Intervention Approaches / Strategies Acute stage / Severe Condition Goals: Reduce the frequency and severity of the headaches Reduce the medication required to manage the symptoms

• Re-injury Prevention Instruction Avoid positions that reproduce or aggravate the headaches

• Manual Therapy

Soft tissue mobilization to the involved suboccipital myofascial restrictions (performed at an intensity that does not aggravating the patient’s condition) Joint mobilization/manipulation to the involved upper cervical facet restrictions (performed at an intensity or velocity that does not aggravating the patient’s condition) Note: Performing upper cervical joint mobilization/manipulations with the patients upper cervical spine at end ranges of extension or the end ranges of combined of extension/rotation movements is contraindicated due the potential disaterous effects that these manipulative procedures have been reported to have some individual’s vertebral artery. Thus, all upper cervical manipulations are performed with the head and neck in the neutral or flexed position

• Therapeutic Exercise: Instruct in exercise and functional movements to maintain the improvements in mobility gained with the soft tissue and joint manipulations (Head nodding and retraction/protraction for O-C1 and rotation for C1-C2)

• Ergnomics Instructions

Postural re-education to limit excessive extended head postitions during occupational tasks, recreational activities and other daily activities

Sub Acute Stage / Moderate Condition


Goals: As above

Normalize upper cervical segmental mobility

• Approaches / Strategies listed above – focusing on restoring normal, pain free occipital and cervical spine mobility.

• Therapeutic Exercise

Low load endurance exercises to train muscle control of the cervical and scapular region, consists of exercises targeting deep neck flexor muscles and longus capitus and colli, trapezius, and serratus anterior. For example, cervical flexion exercises using a pressure biofeedback unit and isometric exercises using rotatory resistance to train the cocontraction of the neck flexors and extensors

Settled Stage / Mild Condition Goals: As above

Normalize cervical and upper thoracic flexibility and strength deficits Increase activity tolerance



Stretching exercises to address the patient’s specific muscle flexibility deficits Strengthening exercises to address the patient’s specific muscle strength deficits Dural mobiliy exercises to address the patient’s specific dural mobility deficits

Intervention for High Performance/High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities


• Therapeutic Exercises Maximize muscle performance of the neck, scapulae, shoulder girdle muscles perform the desired occupational or recreational activities.


Selected References Bansevicius D, Sjaastad O. Cervicogenic headache: The influence of mental load on pain level and EMG of shoulder-neck and facial muscles. Headache. 1996;36:372-8. Bovim G, Berg R, Dale LG. Cervicogenic headache: Anesthetic blockades of cervical nerves (C2-C5) and facet joint (C2-C3). Pain. 1992;49:315-20. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercises and manipulative therapy for cervicogenic headache. Spine. 2002;27:1835-43. Mulligan BR. Manuel Therapy ‘Nags’, ‘Snags’, ‘MWMs’ etc. 4th ed. Wellington: Plane View Press, 1995 Nilsson N. The prevalence of cervicogenic headache in a random population same of 29-to 59-year-olds. Spine. 1995;20:1884-8 Petersen S. Articular and Muscular Impairments in Cervicogenic Headache: A Case Report. Journal of Orthopedic Sports Physical Therapy. 2003;33:21-32. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: Diagnostic criteria. Headache 1998;38:442-5.


MANUAL EXAMINATION AND TREATMENT OF THE UPPER CERVICAL SPINE Symptoms/Signs of Cerebral Anoxia:

Apprehension, anxiety, or panic with cervical movements Vertigo and dizziness Blurred vision Nystagmus Nausea Slowness of Response

Manual Examination: If hypermobility is suspected, examine for instability:

Sharp-Purser Test Odontoid-Alar Ligament Test Hypermobile accessory movements Central tenderness or pain with central posterior-to-anterior pressures

If vascular insufficiency is suspected:

Watch for signs of cerebral anoxia Perform vertebral artery tests – continually assessment of symptoms/signs of cerebral anoxia

Passive Movements:

Physiological Movement Testing: Occiput-C1: Occiput FB/BB

Occiput SB Occiput Lateral Translatory Movements in FB and BB

C1-C2: A/A Rotation in cervical flexion

Accessory Movement Testing: Occiput-C1: C1 Anterior Glide

C1 Lateral Glide Palpation:

Sub-occipital myofascia Manual Treatment Soft Tissue Mobilization:

Sub-occipital myofascia STM Contract-Relax

Occiput-C1 C1-C2

Passive Joint Mobilization:

Occipital Distraction C1 Anterior Glide C1 Lateral Glide C1-C2 Rotation (sitting)

Re-Education:

Neutral Head/Neck Cueing Neck Flexor Therapeutic Exercises

Always remember: While performing all examination and treatment procedures, be alert for signs of cerebral anoxia



C1/C2 Contract/Relax Cues: Fully flex C2 through C7

Adding flexion at the occiput/C1/C2 areas assists in preventing rotation past C2 (i.e., it helps create a “firm” C1/C2 rotation barrier)

Rotate occiput and C1 to the right until the first “barrier” - be sure to 1) maintain the cervical flexion, and 2) prevent cervical sidebending

“Look with your eyes to the left” – Relax – Take up the now available right rotation slack passively (or “gently look to the right”) - relax - repeat contract/relax procedures 3 to 5 times


264, 1992 Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 192, 1996



C1/C2 Rotation Cues: Stabilize the right lamina of C2 with your left thumb

Comfortably hug the patient’s head and rotate it (with C1) to the right Tilt the head to the left to allow some slack in the left alar ligament Apply a passive stretch (or, a contract/relax stretch) Be especially tuned into the patient with regards to VBI symptoms or signs while

performing this technique The following reference provides additional information regarding a similar procedure: Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 279, 1995


Impairment: Limited Occiput/C1 flexion Limited Occipital Posterior Glide (or C1 Anterior Glide) on the Left

Occipital Posterior Glide Cues: Rest the right middle finger on the left thenar eminence

Position the patient (and your hands) so that the left lateral mass of C1 is contacted by the “dummy” middle finger

Apply a posterior glide to the left occipital condyle via a posterior force on the patients left forehead (using flexion of your thorax – with your left anterior deltoid/clavipectoral area contacting the patient’s left forehead)

C1 Anterior Glide


Impairment: Limited Upper Cervical Right Sidebending Limited C1 Right Lateral Translation

C1 Lateral Translation Cue: Contact the left C1 lateral mass with 1) your left index or middle finger, or 2) the radial

side of your left index finger MCP area Stabilize the skull with your right hand Apply right lateral translatory oscillations or stretching forces to C1 Be kind and gentle - but effective Don’t be in a hurry

The following reference provides additional information regarding similar procedures: Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 243, 277,

1993



Occiput/C1 Contract/Relax (of segmental extensors and left sidebenders)

Cue: Nod the occiput to take up the flexion barrier

Translate the nodded occiput to the left to first upper cervical barrier – not mid cervical barrier

Keep the eyebrows parallel to the transverse plane when translating the occiput (to avoid inadvertent left sidebending)

Elicited contraction of the segmental extensors (“look to the left”) Manually cue either the anterior aspect of the chin or the left zygoma (with your left

forearm) when providing the verbal commands Maintain both the flexion and the left translation barriers during the contraction Relax Take up available slack in both barriers Repeat





Occipital Distraction in Flexion and Sidebending Cues: Contact the right occipital condyle with the anterior surface of the index finger

metacarpal of the right hand As best as possible, align your right forearm parallel to the distraction force direction “Hug” the right side of patient’s head with your left forearm Position the patient at the barriers of both flexion and left translation - as he/she exhales The distraction mobilization or manipulation force primarily comes from your index

finger metacarpal – using a weight shift from your trunk If you are not moving the patient’s feet (“positive toe sign”) you are probably not

providing enough traction force to distract the patient’s occiput from C1




Impairment: Limited Occipital Extension and Right Sidebending

Occiput /C1 Contract/Relax (of segmental flexors and left sidebenders)

Cues: Extend the head (not the cervical spine) to take up the extension barrier

Translate the extended head to the left to the first (upper cervical - not mid cervical) barrier Translate left - not sidebend left Elicit contraction of the segmental flexors (“look down toward your feet”) or sidebenders

(“look to the left) Manually cue either under the chin or the left zygoma when providing the verbal

commands Maintain both barriers during the contraction Relax - take up slack – repeat

The following references provides additional information regarding this procedure: John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p. 266, 1992 Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 193-194, 1996

Occipital Distraction in Extension and Sidebending

Cues: Contacts and force application is similar to the occipital distraction in flexion Position the patient at the barriers of occipital extension (not cervical extension) and left

translation - as he/she exhales Maintain these barriers – apply the distraction mobilizations or manipulation

The following references provides additional information regarding this procedure: John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p.268, 1992 Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 201, 1996


Cervical Spine and Related Lower Extremity Radiating Pain ICD-9-CM code: 724.4 cervical radiculitis ICF codes: Activities and Participation Domain code: d4108 Changing a basic body

position, other specified - specified as: extending and rotating the head and neck, such as in looking behind oneself to the left or to the right

Body Structure codes: s76000 Cervical vertebral column s7309 Structure of the upper extremity, other specified

Body Functions code: b28010 Pain in head and neck b2803 Radiating pain in a dermatome


Shooting, narrow band of pain - usually below the elbow Paresthesias Numbness Weakness


May adopt posture to relieve nerve tension Symptoms reproduced with extension and sidebending toward the involved side

(extension quadrant or Spurling’s test) Symptoms reproduced with upper limb nerve tension test May have sensation deficits and strength deficits in the upper extremity

Physical Examination Procedures:

Cervical Extension, Sidebending and

Rotation to the Same Side

Performance Cues:This cervical “Quadrant” narrows the inter vertebral foramen (as well as approximates

the cervical facets) Assess relation between movement and symptom reproduction


Upper Limb Nerve Tension Test

Median Nerve Stretch Test

Performance Cues:Determine baseline level of symptoms Assess change in symptoms as each of the following components of the test are gradually

added - take up the slack only to the initial tissue resistance or report of symptomatology:

1. Scapular depression 2. Humeral abduction (not past 90 degrees) 3. Humeral external rotation (not past 90 degrees) 4. Forearm supination 5. Wrist, thumb, and finger extension 6. Elbow extension

Sensation Tension

Performance Cues: C5 - Lateral anticubital fossa C6 - Anterior distal aspect of thumb C7 - Anterior distal aspect of middle finger C8 - Anterior distal aspect of little finger T1 - Medial aspect of arm, just proximal to elbow Assess light touch and/or sharp-dull, comparing to uninvolved side


C5 - Biceps Brachii MMT C6 - Extensor Carpi Radialis Longus and Brevis MMT

C7 – Triceps MMT

C8 - Flexor Digitorum Profundus MMT T1 - Abductor Digiti Minimi and First Dorsal Interosseous MMT

Performance Cues: Assess motor involvement by using manual muscle tests to determine strength deficits Compare strength to uninvolved side and with norm for age, gender, and activity level Manual muscle test norm is ability to move fully against gravity and take moderate-to-

maximal resistance without giving or fatiguing

Cervical Spine and Related Upper Extremity Radiating Pain

Description, Etiology, Stages, and Intervention Strategies

The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Cervical Radiculopathy”

Description: Cervical radiculopathy is, by definition, a disease of the cervical spinal nerve root. It is most commonly caused by a cervical disc herniation or other space occupying lesion such as a osteophytic encroachment associated with spondylosis or a tumor. This encroachment from a space occupying lesion can result in nerve root impingement, inflammation, or both. The chief symptom is a narrow band of lancinating pain that radiates to the shoulder girdle and upper extremity. The primary signs are unilateral paresthesias , sensory deficits, diminished muscle stretch reflexes and motor deficits in the shoulder girdle and upper extremity.


Etiology: Cervical radiculopathy is usually of non-traumatic origin and occurs spontaneously in the majority of cases. In younger adults the most common cause of this disorder is disc herniation, whereas cervical spondylosis is a more frequent cause in older patients. Peak incidence of cervical radiculopathy is in the fourth or fifth decade of life. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b28010.3 SEVERE pain in head and neck; and b2803.3 SEVERE radiating pain in a dermatome

• Posture or positioning to relieve tension on the related nerve (e.g., cervical flexion or

sidebending, elevated scapula, arm supported or held with wrist resting on head) • Positive Shoulder Abduction Test relieves symptions (i.e., the patient elevates arm

overhead and places hand on head to bring on a relief of symptoms) • Decreased cervical rotation (cervical rotation < 60°) • Positive Spurling’s Test (i.e., cervical extension/sidebending/rotation toward the

involved side with compression reproduces radicular symptoms) • Positive Manual Traction Test (i.e., axial manual traction to cervical spine relieves

symptoms) • Peripheralization or centralization of symptoms with repeated movements • Positive Upper Limb Tension Test (i.e, tension or stretch of the involved nerve root

and its associated nerve reproduces the radicular symptoms) • Positive neurological signs (i.e., diminished sensation to the skin served by the

involved nerve root and motor weakness of the muscles served by the involved nerve root and diminished deep tendon reflexes associated with specific nerve roots)

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28010.2 MODERATE pain in head and neck; and b2803.2 MODERATE radiating pain in a dermatome

• As above – the severity of the radicular signs may resolve as the inflammation around the involved nerve root diminishes

• Now (when less acute) assess upper quarter postural alignment, muscle balance (i.e., muscle flexibility and strength deficits), and pertinent ergonomic factors contributing to the patient’s symptoms/functional limitations

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28010.1 MILD pain in head and neck; and b2803.1 MILD radiating pain in a dermatome

As above with the following differences:

• Radicular symptoms are reproduced only with end-range sustained positions of the cervical spine or sustained tension positions of the involved nerve root and it associated upper extremity nerve


Clinical Examination for Cervical Radiculopathy (Wainer)

• If three of the four following tests are positive the probability of the condition

increases to 65%. • If all four of the following tests are positive the probability of the condition increases

to 90%. • If ULTTA is negative, the probability of the condition is 3%, essentially Cervical

Radiculopathy can be ruled out.

1. ULTTA (Upper Limb Tension Test A)

2. Involved cervical rotation less than 60°

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Improve neurological status

Reduce radicular pain

• Re-injury Prevention Instruction Limit movements or activities that aggravates the symptoms. For example, use of 1) a soft cervical collar, or 2) slight cervical flexion, sidebending opposite of radiculopathy and retraction positions and motions increase neural foraminal size – may be used to reduce further forminal aggravation during the inflammatory stage.


Nerve mobility execises in painfree ranges

• Manual Therapy Manual cervical traction Soft tissue mobilization to the myofascial restrictions in the areas of upper extremity nerve entrapments associated the involved nerve root

• Neuromuscular Reeducation

Facilitate cervical positions that optimally open the involved foramin – typically by promoting neutral positions of the thoracic cage, scapular, neck and head positions during daily activities.

Sub Acute Stage / Moderate Condition: Goal: Prevent recurrence




Stretching exercises to address the patient’s specific muscle flexibility deficits Strengthening exercises to address the patient’s specific muscle strength deficits

Settled Stage / Mild Condition: Goal: Progress activity tolerance


• Therapeutic Exercises Maximize muscle performance of the relevant trunk, scapulae, shoulder girdle and neck muscles required to perform the desired occupational or recreational activities

• Ergonomic Instruction Add job/sport specific training

Intervention for High Performance/High Demand Functioning in Workers or Athletes: Goal: Return to desired occupational or leisure time activities

• Approaches / Strategies listed above Selected References Abdulwahab SS, Sabbahi M., Neck retraction, cervical root decompression, and radicular pain. J Ortho Sports Phys Ther. 2000; 30: 4-8 Davidson RI., Dunn EJ., Metzmaker JN. The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies. Spine. 6:441-6, 1981. Farmer JC., Wisneski RJ. Cervical spine nerve root compression. An analysis of neuroforaminal pressures with varying head and arm positions. Spine. 19:1850-5, 1994. Humphreys SC., Hodges SD., Patwardhan A., Eck JC., Covington LA., Sartori M. The natural history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years as measured by magnetic resonance imaging. A descriptive approach. Spine. 23:2180-4, 1998.


Jordan A., Bendix T., Nielsen H., Hansen FR., Host D., Winkel A. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. A prospective, single-blinded, randomized clinical trial. Spine. 23:311-8, 1998. Lentell G., Kruse M., Chock B., Wilson K., Iwamoto M., Martin R. Dimensions of the cervical neural foramina in resting and retracted positions using magnetic resonance imaging. J Orthop Sports Phys Ther. 32:380-90, 2002 Muhle C., Resnick D., Ahn JM., Sudmeyer M., Heller M. In vivo changes in the neuroforaminal size at flexion-extension and axial rotation of the cervical spine in healthy persons examined using kinematic magnetic resonance imaging. Spine. 26(13):E287-93, 2001 Persson, Liselott CG. et al. Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar. Spine. 1997; 22:751-758 Radhakrishnan K., Litchy WJ., O'Fallon WM., Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 117 ( Pt 2):325-35, 1994. Saal S, Yurth E.F. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine. 1996; 21:1877-1883 Van der Heijden GJ., Beurskens AJ., Koes BW., Assendelft WJ., De Vet HC., Bouter LM. The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods. Phys Ther. 75(2):93-104, 1995. Viikari-Juntura E, Porras M., Laasonen E.M. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine. 1989; 14:253-257. Wainner RS., Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther. 2000;30:728-744. Wainner RS., Fritz JM., Irrgang JJ., Boninger ML., Delitto A., Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 28(1):52-62, 2003. Wolff MW, Levine LA. Cervical radiculopathies: conservative approaches to management. Phys Med Rehabil Clin N Am. 2000, 13:589-608


Cervical and Shoulder Examination

Algorithm #1

Yes

No

Yes If Negative

If Negative

Suspect 1) Fracture or Loss of Connective Tissue Integrity Due to Trauma or Disease, and/or 2)

Abnormal/Hypermobile Cervical Segmental Mobility

Cervical Examination Algorithm #2

Consultation with Appropriate

Healthcare Provider

Screen for Potentially Serious Non-Musculoskeletal

Pathology

Medical Clearance and Negative Imaging

Stabilization Procedures

Emmanuel Yung PT, MA, OCS Skulpan Asavasopon MPT, OCS Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

Cervical Examination and Intervention

Algorithm #2

Pain During Movement or Pain Does Not Limit Motion Pain Limits Motion in Available in Available Ranges and/or Ranges or Movement Produces Pain at End of Range Does Not Peripheral Symptoms Produce Peripheral Symptoms If Positive for Upper Motor Neuron Produces Lesions Vertebro- Basilar Insufficiency Produces Peripheral Symptoms Signs Does Not Produce If Safe to Proceed Peripheral Symptoms If Segmental Instability If Negative If Symptoms Unresolved If Positive If Negative

Neurological Status

Examination

Mobility Examination of • Upper Quarter Neural Elements • Peripheral Nerve Entrapment Sites

Nerve Entrapment Reduction Procedures

Cervical Stabilization Procedures

If Symptoms Resolve to the Point Where Pain Does Not Limit Motion in Available Range, Return to Single Plane

Active Mobility Examination

Pain Limited Nerve

Mobility

Consultation with Other Healthcare Providers

Cervical Spine Side Bending, and/or Combined Side

Bending/Rotation /Extension

Over Pressures

Vertebrobasilar Insufficiency Exam

Mobility Examination of: • Upper Thoracic and Cervical Spine • Upper Quarter Neural Elements

Mobilization of Upper Quarter Neural Elements

Mobilization of Cervical and Thoracic

Spinal Segments

Pain Limited Cervical Mobility

To Algorithm #3 Shoulder Examination

Resistance Limited Cervical Mobility

Resistance Limited Nerve

Mobility

Cervical and Upper Thoracic Single Plane

Active Mobility Examination


Shoulder Examination and Intervention Algorithm #3a

Active ROM Tests: 1) Elevation 2) 90/90 or Neutral External Rotation 3) Hand Behind Back

Passive ROM Tests: 1) Elevation with Over Pressure 2) Isolated Glenohumeral External Rotation\ 3) Isolated Glenohumeral Internal Rotation

To Algorithm #3b

Palpatory Examination of Suspected Enthesopathy

Resisted Tests: 1) External Rotation 2) Abduction Active Compression3) Flexion Test

Passive Accessory Motion Tests: 1) Posterior Humeral Translation 2) Anterior Humeral Translation 3) Inferior Humeral Translation (sulcus sign) 4) Acromioclavicular Accessory Movements


or continuum

If Symptoms Unresolved

Algorithm #3b • Night Pain • Weak External Rotators • Over 65 Years of Age

Medical/Surgical Consultation in Addition to PT

Intervention

Pain Limits Active and Passive Movements in

Mid Ranges

• Normal or Excessive Active and Passive Range of Motion

• Painful and/or Excessive Humeral Accessory Motions

• Positive Active Compression Tests

• Pain with Active Motions • Pain with Passive Over Pressure • Weak and/or Painful Resisted Tests

• Limited Active and Passive Range of Motion

• Limited Humeral Accessory Motions

Physical Agents and Ergonomic Counseling

Shoulder Strengthening Therapeutic Exercises

Shoulder Strengthening

Therapeutic Exercises

Shoulder Mobilization Procedures

If Symptoms Resolve, and Pain No Longer Limits Active and Passive

Movements in Mid Ranges, Return to Start of Algorithm #3

Associated Upper Quarter Impairment Examination

Algorithm #4

Suspect Rotator

Cuff Tear

Resistance Limited Shoulder Mobility

Impingement

Instability

• First Time Traumatic Dislocation

• Age ≤25 Years Old

Suspect Glenohumeral

Capsuloligamentous Labral Tear

Consultation with Other Healthcare Providers

• Dislocation • Over 40 Years of Age • Shoulder Elevation <90

degrees after 6 weeks

Medical/Surgical Consultation in Addition to PT

Intervention

Pain Limited Shoulder Mobility


Associated Upper Quarter Impairment Examination

Algorithm #4

Physical Agents and Ergonomic Instructions

Shoulder Strengthening Therapeutic Exercises

Shoulder Stabilization

Procedures and Therapeutic Exercises

Nerve Entrapment Reduction Procedures

Cervical Stabilization Procedures

Mobilization of Upper Quarter

Neural Elements

Mobilization of Cervical and

Thoracic Spinal Segments

Strength/Motor Control/Endurance Deficits Deep Neck Flexors Lower Trapezius Middle Trapezius Serratus Anterior

Shoulder Mobilization Procedures

Postural Deficits Excessive Capital Extension Protracted Scapulae Excessive Thoracic Kyphosis

Flexibility Deficits Levator Scapulae Pectoralis Major Pectoralis Minor Upper Trapezius Latissimus Dorsi Subscapularis Suboccipital Myofascia Teres Major Sternocleidomastoid


Selected References Aker PD, Gross AR, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ.

1996;313:1291-6. Antonaci F, Ghirmai S, Bono G, Sandrini G, Nappi G. Cervicogenic headache: evaluation of the original diagnostic criteria. Cephalalgia. 2001;21:573-

83. Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: a clinical evaluation. Spine. 1990;15:458-61. Aspinall W. Clinical testing for the craniovertebral hypermobility syndrome. J Orthop Sports Phys Ther. 1990;12:47-54. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J

Orthop Sports Phys Ther. 2000;30:126-37. Bigliani LU, Kelkar R, Flatow EL, Pollock RG, Mow VC. Glenohumeral stability. biomechanical properties of passive and active stabilizers. Clin Orthop

Rel Res. 1996;330:13-30. Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin

Orthop Rel Res. 1993;294:103-10. Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial of exercise and spinal manipulation for patients with

chronic neck pain. Spine. 2001;26:788-97. Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens.

Ann Rheum Dis. 1984;43:353-60. Burkehead WZ, Rockwood CA. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg. 1992;74A:890-6. Calis M, Akgun K, Birtane M, Karacan I, Tuzun F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis.

2000;59:44-7. Chesworth BM, MacDermid JC, Roth JH. Movement diagram and "end-feel" reliability when measuring passive lateral rotation of the shoulder in patients

with shoulder pathology. Phys Ther. 1998;78:593-601. Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence.

Pain. 1993;52:259-85. Conroy DE, Hayes KW. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J

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106.


SUMMARY OF CERVICAL SPINE DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES DISORDER HISTORY PHYSICAL EXAM PT MANAGEMENT “Cervical Facet

Syndrome” 723.1 onov* = 4 or less

mnov** = 8

Unilateral neck pain – commonly with referral (from occiput to scapula)

Strain, unguarded or awkward movement or position

SR with: End range rotation left or right

Palpation of involved facet Restricted accessory movement of

the involved facet

Segmental STM and C/R Joint mob/manip Ther Ex’s

“Cervicogenic Headache”

723.2 onov = 4 or less mnov = 12

Unilateral neck pain with referral to occipital, temporal, parietal, frontal or orbital areas

HA precipitated/aggravated by neck movements or sustained positions

Noncontinuous HA (usually < 1 episode/day, < 2 episodes/week)

Observable postural asymmetry of the head on neck (sidebent or extended)

HA reproduced with provocation of the involved segmental ST/Joints

O/C1, C1/C2, or C2/C3 restricted accessory motions with associated myofascial trigger points

Postural re-education Ergonomic Instructions ST and joint mob/manip (w/ the head

and neck in neutral) to the restricted segmental motions

Address related upper ¼ muscle imbalances and joint impairments

Upper cervical Ther Ex’s “Cervical

Radiculopathy” 724.4 onov = 8 or less

mnov = 20

Lancinating pain to UE Paresthesias Numbness Weakness

SR with: Ext/SB to same side ULTT

May have neuro signs (UE sensory, motor, and reflex deficits)

Patient education (Positions of reduced nerve entrapment/tension)

Manual or mechanical traction Reduce entrapment (STM, JM,

Nerve mob, ergonomic cuing, postural cuing, Ther Ex - where indicated to address the patient’s impairments)

Cervical Ligament Sprain

847.0 onov = 8 or less

mnov = 20

Trauma Protective muscle spasm

Pain with motion – worsens at end range

SR with palpation or provocation (via central PA’s of the involved ligament or segment)

May have laxity with ligamentous stress tests

Stabilization (C-collar, Ther Ex, positioning, ergonomic cuing)

Rx mobility impairments of adjacent segments or regions

Later, add strength and endurance training if applicable

onov = optimal number of visits mnov = maximal number of visits SR = Symptom Reproduction

Joe Godges, DPT, MA, OCS KP So Cal Ortho PT Residency

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Mid-Cervical Spine Fusion

Anatomical Considerations: The cervical spine consists of several joints. It is an area where stability has been sacrificed for mobility, making the cervical spine particularly vulnerable to injury. The superior apophyseal (aka facet) joints of each segment face upward, backward, and medially. The inferior facets face downward, forward, and laterally. This facet orientation facilitates flexion and extension, but it prevents isolated rotation or side flexion. Thus, rotation and sidebending occur together (i.e., coupled) in the mid-cervical spine. These joints move primarily by gliding and are classified as synovial (diarthrodial) joints. The greatest flexion-extension of the facet joints occurs at C5 and C6; however, there is almost as much movement at C4-C5 and C6-C7. Because of this mobility, degeneration is most likely to be seen at these levels. The neutral or resting position of the cervical spine is slightly extended. The closed packed position of the facet joints is complete extension. The intervertebral discs make up approximately 25% of the height of the cervical spine. Pathogenesis: The cervical spine can be structurally compromised by differing mechanisms, such as instability resulting from trauma or the degenerative processes associated with aging. The degenerative process involving the cervical spine is also known as cervical spondylosis. Disc degeneration and osteophyte formation are present on radiological studies in a majority of the population by the age of 55, yet many people never develop symptoms. Cervical disc degeneration occurs most commonly at the C5-C6 and the C6-C7 levels. The decreased water content of the disc may result in a narrowing of the disc space and loss of disc height, which increases the shearing motion at the affected disc space and further contributes to the degenerative process. Many people develop osteophytes along the spine as a result of the degenerative process. These osteophytes may compress or irritate the cervical nerve root at the affected level or levels. Fissures may develop in the annulus, which can allow portions of the nucleus to protrude through the annulus. Disc herniations may irritate or compress the spinal nerve roots exiting the spinal cord, causing pain or numbness along the distribution of the nerve. The degenerative process can also cause narrowing of the spinal canal (spinal stenosis), compression of the spinal cord, or compression of the vessels supplying the spinal cord, resulting in cervical myelopathy. Cervical myelopathy may produce numbness and weakness in the upper extremities (lower motor neuron signs) and can also cause long track (upper motor neuron) signs affecting lower extremity function. Infections or tumors of the vertebral column can greatly exaggerate the deleterious neurological changes and subsequent loss of function. Epidemiology: Research into the epidemiology of cervical disc disease indicates that men are affected more often than women by a small margin. Most people with symptomatic herniated cervical discs are in their 40’s and 50’s. Cigarette smoking also is associated with increased incidence of cervical disc disease. The most common symptoms seen in patients for treatment of cervical degenerative disc disease are neck pain, occipital headaches, pain and numbness radiating to one or both shoulders, the scapular region, or arms and hands. Many patients have radicular symptoms, which are pain, paresthesias, motor and sensory deficits due to disorders of the nerve roots, typically due to compression at the cervical lateral forminal canal. Radicular pain can be aggravated or relieved by the patient’s neck and head position. Neck flexion can relieve symptoms in some patients, and lateral flexion or rotating the head

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT, MA, OCS

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toward the affected arm may increase pain and numbness. Diagnosis: A combination of plain radiographs and magnetic resonance imaging (MRI) with or without computed topography (CT) myelograms often is used in the diagnosis of patients presenting with symptoms of degenerative cervical disc disease. Plain x-ray films can be used to determine whether cervical entophytes are present and whether a loss of disc height is present in the cervical spine. The disc space and cervical nerve roots can be examined by MRI scan to identify disc herniation. Compression of the spinal cord or nerve roots can be identified with CT myelograms. Non-operative versus Operative Management: Conservative treatment for patients with symptomatic degenerative disc disease includes rest, pain medication, non-steroidal anti-inflammatory medications, physical therapy including: intermittent cervical traction, positioning, ice/heat, ultrasound/phonophoresis, electrical stimulation, soft tissue mobilization, joint mobilization, nerve mobilization, exercises for flexibility, strength, coordination and overall fitness; posture and ergonomics. Many patients benefit from conservative treatment and experience a resolution of symptoms. Patients who continue to have pain, numbness, or weakness, despite conservative therapy for approximately 6 to12 months, may be candidates for surgical intervention. However, host factors that have a negative impact on obtaining a fusion play a role in determining whether a patient is a candidate for surgery. These factors include cigarette smoking (nicotine is a bone toxin), osteoporosis, chronic steroid use, and malnutrition. Surgical Procedures: Anterior Cervical Discectomy and Fusion (ACDF): The patient is placed supine on the table. Under general anesthesia, the neck is draped in sterile manner. The correct level is identified under x-ray control. A transverse incision of approximately 1.8 cm is made at the desired level. After the incision the sternocleidomastoid and the strap muscles are identified. The anterior surface of the cervical spine is exposed. The longus colli muscles are reflected laterally at the C4-5 level and the level is once again identified under x-ray control. A self-retaining Cloward retractor is placed and the disk space is identified.

Anterior Cervical Diskectomy: With the help of pituitary forceps and curettes, the disk is removed as posteriorly as possible. The posterior longitudinal ligament is visualized. Further disc is removed from the foramina on both sides. The foramen is probed with a nerve hook and further decompression is carried out with the help of Kerrison rongeur.

Anterior Cervical Fusion: The end plates are lightly burred with a high-speed burr to expose the bleeding subchondral bone. Sizing of the disc is performed. Appropriate allograft is taken and inserted in the disc space under tension. The graft fixation is checked for fit.

Cervical Plating: The appropriate sized cervical plate is selected. It is applied to the anterior surfaces of the involved vertebra. Position is identified under x-ray control. This is fixed to the vertebrae with the help of four 14mm screws. The fixation is checked. The wound is irrigated and deeper tissues are closed with sutures and then, the skin is closed with sutures. Marcaine is injected into the edges of the skin. A sterile dressing is applied and a cervical


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collar is given. The patient is awakened and transferred to the recovery room. Discectomy and Posterior Microendoscopic Fusion (Posterior Approach). This approach is commonly usually used with cervical spine fractures. The patient is placed in the semi-sitting position. A skin incision of 1.8 cm is made 1.5 cm laterally from the midline. Under radioscopy, the progressive dialators are inserted through the paravertebral muscles up to the cervical laminae. After the tubular retractor is inserted, the optic fiber and camera are adjusted. The remaining part of this procedure is very similar as the anterior approach. The semi-sitting position prevents the excess of venous epidural bleeding. The ACDF procedure is associated with a low overall rate of complication. Retrospective studies of patients after ACDF indicate that 80-90% of patients have good to excellent outcomes, including relief of symptoms and successful fusion. However, there are many surgical complications. These include hoarseness of voice (usually temporary but can be permanent); temporary dysphasia; esophageal, tracheal, or vertebral artery injury; wound infection; injury to the spinal cord or nerve root; dura mater tears with associated cerebrospinal fluid leaks; pseudoarthrosis caused by nonunion of fusion; graft extrusion; and screw loosening. Preoperative Rehabilitation: Preoperative treatment is to establish a conditioning program for surgery. Included in this program is keeping the affected joint from excessive mechanical forces and instructing the patient in proper postural body mechanics and exercise program. Medications such as non-steroidal anti-inflammatory drugs, acetaminophen, muscle relaxants, and possible narcotics are prescribed for pain control. Spinal injections can be used for both treatment and diagnostic purposes. Injections usually use a mixture of an anesthetic and some type of cortisone preparation. The anesthetic numbs the area of the injection site. If the injection takes away the pain immediately, suggests that the injection site is indeed the source of the pain. The cortisone decreases inflammation and can reduce the pain from an inflamed nerve or joint for a prolonged period of time. Types of injections include: epidural steroid in injection (ESI), selective nerve root injection, facet joint injections, and trigger point injections.

POSTOPERATIVE REHABILITATION

Note: The following rehabilitation progression is a combination of guidelines provided by Bhatnagar et al. Refer to this publication to obtain further details. Phase I: 1-10 days post-op Goals: Protect repair

Control pain Independence in activities of daily living Minimize deconditioning


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Intervention:

• Patient may be instructed and fitted for home bone stimulation unit • Instruct in proper positioning and controlled movement • Other considerations:

The wounds are usually sore for about 5 days. The hip will always hurt more than the cervical spine if this was the donor site. The patient is allowed to shower after about 2-3 days post-op. No bathing or swimming. It is common to have initial problems with swallowing. Complaints of a hoarse voice may be present - this should improve over the next 3 month.

Phase II: 2-12 weeks post-op. Goals: Continue to protect fusion

Continue to control pain Increase active and passive range of movement Normalize movement patterns Increase endurance, aerobic conditioning.

Intervention:

• Ergonomic instruction - The patient is advised to not lift more than 2 pounds and avoid sudden movements of the neck for the initial 6 weeks.

• Progressive ambulation for the first 6 weeks is the safest and easiest exercise to develop stamina. It is suggested that 2-4 shorter distance walks are more beneficial rather than once for long distance.

• After 6 weeks patient is advanced to other low-impact aerobic activities: Stairmaster, upper body ergo meter, stationary bicycle and swimming.

• Other Considerations: For the initial 6 weeks the patient is instructed to NOT vacuum, sweep, garden, make the bed, perform home repairs, or carry heavy items like children, wet laundry, or firewood. Some patients will be allowed to drive after about 6 weeks. Some patients might return to work after approximately 4-6 weeks depending on occupation, recovery and complications after surgery. All patients are instructed to refrain from heavy lifting (>22 pounds) for the first year.

Phase III: usually after 3 month.

• Progress therapeutic exercise programs to include passive extremity stretching strengthening with a full progressive resistive exercise program using isotonic, isometric, and isokinetic exercises.


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• Other considerations: Minimal control is provided with soft collars but they provide warmth and proprioceptive feedback and are inexpensive and convenient.

Phase IV: Autonomous stage: (On-going) Goals: Return to high level/high intensity activities for prolonged periods of time. Intervention:

• Work hardening/conditioning • Dynamic co-ordination and balance activities

These post-surgical exercises are very similar activities used to prevent surgery and have been shown to be an effective treatment with long-term reductions in pain and functional disability in subjects diagnosed with cervical segment instability and chronic cervical pain. For operative or for non-operative patients the approach is the same, it is based on a motor learning model where faulty movement patterns are identified and components of movement are isolated so they can be retrained into functional tasks.

Selected References: Bhatnagar M, et al. Spinal Fusion and Rehabilitation Aftercare. www.simmonsortho.com. 2004. Brown C., Eismont F. Complications in spinal fusion. Orthopedic Clinics of North America. 1998;29: 679-697. Cherry, C. Anterior cervical discectomy and fusion for cervical disc disease. AORN Journal. www.looksmart.com. 2003. Melbourne Neurosurgery. Anterior Cervical Discectomy and Fusion post operative information. www.neurosurgery.com.au. 1-15-2005. Omura K., et al. Evaluation of posterior long fusion versus conservative treatment for progressive rheumatoid cervical spine. Spine. 2002;27;1336-1345. Sasso, R. M.D. Screws, Cages or Both? www.spineuniverse.com 7-31-2003. Pimenta LMH. Cervical Spine Approaches by Metrix. www.spineuniverse.com. 12-12-2003. Vaccaro A., et al. Cervical trauma: rationale for selecting the appropriate fusion technique. Orthopedic Clinics of North America. 1998;29:745-754.


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http://www.neurosurgery.com.au/

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Upper Cervical Spine Fusion Surgical Indications and Considerations Anatomical Considerations: The occiput-C1 articulations primarily allow for flexion and extension movements and the C1-C2 articulations primarily allow for rotation. Fifty percent of cervical spine rotation occurs at the C1-C2 joint complex. Pathogenesis: Upper cervical instability can occur from intrinsic factors, such as rheumatoid arthritis, or extrinsic factors, such as trauma. Rheumatiod arthritis most commonly affects the cervical region as compared to the thoracic and lumbar regions. In the affected cervical spine, articular cartilage is destroyed and the inflamed soft tissue enlarges to involve the neighboring structures. Ligaments undergo “distention, attenuation,” and rupture. Bone erosion occurs with osteoporosis, and cyst formation develops which can lead to changes in vertebral alignment in the upper and subaxial cervical spine. Rheumatoid arthritis can also lead to lesions such as atlantoaxial subluxation, atlantoaxial impaction, and subaxial subluxation. These lesions can cause compression of the spinal cord and can lead to generalized debility that can “culminate” into tetraparesis or death. Instability of the atlantoaxial joint can also occur congenitally, such as in the case of Down syndrome. Extrinsic factors such as hyperextension injuries from motor vehicle accidents or falls can lead to instabilities of the upper cervical segments. Hangman’s fractures or C2 traumatic spondylolisthesis involves a fracture to the pars interarticularis of the dorsal element. Other pathological conditions that can warrant a spinal fusion are atlanto-occipital subluxation/dislocation, atlas fractures, odontoid fractures, and occipital condyle injuries secondary to an avulsion of an ipsilateral alar ligament and supporting soft tissue structures as a result of excessive “shear, lateral bending, and rotary forces.” Epidemiology: As mentioned above, rheumatoid arthritis is a major contributing factor related to cervical lesions. Cervical spine subluxations are observed in 43 to 86% of patients, and occur more in males, despite a greater propensity for rheumatoid arthritis in women. According to a study, atlantoaxial subluxation and basilar “invagination” occur in 39% and 11% of patients with rheumatoid arthritis. Clinically, these patients present with severe neck pain, as well as myelopathy from craniocervical instability and spinal cord compression. If left untreated, the condition can cause neurological decline, patients can become bedridden, and the chances of surviving beyond seven years is unlikely. Extrinsic biomechanical stress to the cervical spine is another factor which can contribute to cervical lesions. Upper cervical spine injuries resulting from trauma includes: 1)occipital condyle injuries resulting from an avulsion of the ipsilateral alar ligament from excessive shear, lateral bending, and rotatory forces, 2) atlanto-occipital subluxation/dislocation (survivals of this injury are rare) these injuries can cause a severe amount of instability and can be associated with cranial nerve and spinal cord involvement, 3) atlas fractures which can lead to C1-C2 instability due to “incompetency” of the transverse ligament and surrounding capsular structures, and 4) odontoid fractures, which account for 5-15% of cervical spine fractures.


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Diagnosis: • For upper cervical disc herniation clinical presentation may include numbness of the

hands and arms, loss of fine motor control, dysesthesia or hypesthesia to pinprick stimulation, proprioception loss, ascending tingling and numbness in fingers, paresthesia over arms, neck pain, and loss of balance

• Mechanism of injury includes hyperextension or hyperflexion injuries involved with motor vehicle accidents or a fall from a height

• Clinical assessment include utilizing the alar ligament testing, Sharp-Purser testing, VBI insufficiency tests, and neurological status examination

• MRI and CT scans are helpful in demonstrating the presence, location, and severity of any fractures, subluxations, or cord compression

• Radiographs are also used to rule out bone pathology such as collapse of the vertebral bodies and osteophyte formation.

Nonoperative Versus Operative Management: Fusion of the upper cervical spine is usually recommended for patients who are unsuccessful with conservative interventions, such as ergonomic cuing, postural education, cervical stabilization/strengthening exercise and manual therapy for mobilization of soft tissue and joint mobility deficits in the upper and mid cervical spine segments. The severity of the cervical lesion shown on imaging studies (MRI, CT scan and X-rays) as well as the patient’s clinical presentation will determine if surgery for spinal fusion is indicated. Radiographic findings such as 1) osteophyte formation into the spinal canal, 2) spinal cord compression, and 3) odontoid and/or atlas bony involvement are all indications for surgical stabilization. Surgical intervention does not guarantee that the existing problem will be cured. There is always the possibility of post surgical complications. Early postoperative complications (up to 1 month postoperatively) include infection, neurologic injury (delayed paresis), graft extrusion (anteriorly and posteriorly), instrumentation loosening and failure. Late postoperative complication can involve the adjacent vertebra segments because the fusion will change the biomechanics of the cervical spine by placing increased stress on the non-fused joints, thus increasing the risk of creating an instability in the segments adjacent to the surgically fused segments. Higher complication rates associated with preoperative and intraoperative risk factors include:

• Obesity • Smoking • Diabetes • Osteoporosis • Pulmonary conditions • Malnutrition • Cerebral palsy • Myelodysplasia • Longer surgical procedures • Increased operating room traffic • Failure to use antibiotics


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Surgical Procedures: Anterior Cervical Spinal Fusion: The procedure provides wide, bilateral exposure, it decreases the incident of contamination of the oral and pharyngeal cavities, and it gives the surgeon access to segments below C4. The patient is positioned supine with the head slightly extended and rotated 30 degrees away from the surgical side. The surgeon makes an incision 2 cm below and parallel to the mandible. A vertical incision of the platysma is made and is transected horizontally. The submandibular gland is elevated, and the facial artery and vein are dissected free. The digastric, hypoglossal, pharyngeal constrictor, longus colli, longus capitus muscles along with the hypoglossal and superior laryngeal nerves and the ventral vertebral and carotid arteries are carefully dissected and retracted to expose the anterior tubercle of C1, C2 and C3 so they can be palpated. An allograft or autograft can be used depending on the patient requirement. The grafts can be bone used from the humerus or the ilium. A plate is selected and is measured to insure the distance from the top of the graft to the body of C3 caudally. Four bicarbonate screws are used to secure the plate onto C1 and C3. Radiographic images are used to help guide the pins and screw placements. Posterior Cervical Spinal Fusion: The patient is positioned in prone. If the neck is stable, the patient’s head is flexed forward to no further than a “finger-width” from the sternum. If not stable, the procedure will be completed with the patient in the neutral position in traction or halo immobilization. A posterior midline incision is made from the external occipital protuberance caudally to allow sufficient exposure as far as C3 level. The dissection is kept midline and “subperiosteally” to expose the spinous processes and laminae of C2 and C3 as far lateral as the facet joints. Uncovering of the posterior arch of the atlas is performed with care. The occiput is exposed if it is included in the fusion, and hemostasis is achieved by electrocautery. For C1-C2 fixation using the Magerl’s transartcular screw placement technique, long screws are placed from the posterior aspect of C2 facet laminar junction to the C1 lateral mass by drilling. Titanium lag screw of the desired length is used with its lagged part only in the C1 portion to provide “compression fixation.” Radiographic images are used to help guide screw placements. Damage to the vertebral artery can result. If damage to vertebral artery occurs with the placement of the first screw, placement of the second screw is avoided. Lateral mass fixation at C2-C3 level can also be achieved posteriorly. With this procedure, a titanium plate is positioned over the facet joints and screws of 14 to 18 mm in length are inserted through the lateral mass of C3 and into the pedicle of C2. This procedure is useful with facet dislocation type injuries and instability at the level of the laminectomy. Preoperative Rehabilitation: Since pathology due to rheumatoid arthritis involving the cervical spine is linked with severe peripheral joint involvement, an attempt at slowing the “progression” early by medical intervention is promoted. Monitoring the spine continuously with radiographic as well as neurological examination is an important aspect of non-operative management. Non-operative treatments include: cervical collars (may help decrease local discomfort), soft tissue mobilization, strengthening/stabilization exercises, transcutaneous electrical nerve stimulation, and anti-inflammatory medications.


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POSTOPERATIVE REHABILITATION

Phase I: Hospital setting: 1-7 days post operation. Goals: Control pain and swelling

Protect fusion Intervention:

• Immobilization with rigid collar brace for 4-8 weeks • Anti-inflammatory and pain medication

Phase II: After discharge: Post-op 4-8 weeks Goals: Control pain

Protect fusion Increase endurance Movement into painfree range

Intervention:

• Rigid collar brace if indicated by physician • Anti-inflammatory and pain medication • Gentle AROM exercises into painfree ranges • Strengthening exercises to tolerance – especially focus on endurance training of cervical

neck flexors • Patient education of proper postural mechanics with functional activities

Part III: Outpatient physical therapy reconditioning program-3 phases Phase I: Cognitive stage: 4-8 weeks Goals: Protect the fusion

Control pain and inflammation Maintain upright posture and neutral spine with functional activities Increase soft tissue mobility of the cervical and scapular muscles

Intervention:

• Ice, hot packs, electrical stimulation, and soft tissue mobilization • Postural re-education to maintain upright posture and neutral spine • Passive and active stretches to the neck and shoulder complex • Static cervical and dynamic scapular stabilization program


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Phase II: Motor Learning: 8 weeks to 4 months Goals: Progress cervical and scapular dynamic stabilization

Progress with endurance and upper extremity program Intervention:

• Scapular and extremity strengthening while maintaining neutral spine • Upper extremity endurance program (e.g., UBE, elliptical rider) • Functional training simulating functional activities

Phase III: Autonomous stage: (on-going) Goals: Return to unrestricted activity Intervention:

• Work hardening and conditioning Note: Most surgeons allow their patients to return to normal unrestricted activity and do not recommend physical therapy after postoperative intervention. Selected References Benzel E. Upper cervical and occipitocervical arthrodesis. Spine Surgery: Techniques, complications avoidance, and management. Philadelphia, Elsevier, 2005. Brown C., Eismont F. Complications in spinal fusion. Orthopedic Clinics of North America. 1998;29: 679-697. Chen T. The clinical presentation of uppermost cervical disc protrusion. Spine. 2000; 25:439-442. Craig E. Rheumatoid arthritis of the spine. Cervical spine trauma: upper and lower cervical spine injury. Clinical Orthopaedics. New York, Lippincott Williams & Wilkins, 1999. Harm J., Melcher R. Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine. 2001; 26:2467-2471. Leamer, T. Lumber spine fusion. University of Pacific, Power point presentation. 2004 Matsunaga S., et al. Prognosis with upper cervical lesions caused by rheumatoid arthritis. Spine. 2003; 28:1581-1587.


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Omura K., et al. Evaluation of posterior long fusion versus conservative treatment for progressive rheumatoid cervical spine. Spine. 2002;27;1336-1345. Sandhu F., et al. Occipitalcervical fusion for rheumatoid arthritis using the inside-outside stabilization technique. Spine. 2003; 28:414-419. Tan M., et al. Morphometric evaluation of screw fixation in atlas via posterior arch and lateral mass. Spine. 2003; 28:883-895. Vaccaro A., et al. Cervical trauma: rationale for selecting the appropriate fusion technique. Orthopedic Clinics of North America. 1998;29:745-754. Vender J., et al. Fusion and instrumentation at C1-3 via high anterior cervical approach. J Neurosurg. 2000;92:24-29.


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Thoracic Outlet Release Surgical Indications and Considerations AnatomicalConsiderations: There are three potential spaces for compression or entrapment through the thoracic outlet. The first is the interscalene triangle located within the posterior triangle of the neck. Within this triangle, the subclavian artery and brachial plexus lie. The sublcavian vein usually lies anterior to the anterior scalene, outside the triangle. Therefore, compression usually produces neurological and/or arterial symptoms. The second potential space is the costoclavicular interval, which is between the clavicle and first rib. The final potential space is the axillary interval. This area is made up of the deltopectoral fascia, the pectoralis minor, and the coracoid all of which can put pressure on the neurovascular bundle composing the thoracic outlet. Pathogenesis: The etiology of TOS symptoms can be vascular (venous or arterial), neurologic, autonomic, or a combination of the three. Compression usually creates symptomatology in the medial cord distribution (radial three digits and volar aspect of the forearm). Late neurological symptoms may include pain and/or sensory changes and paresthesias distributed over the face, posterior and lateral neck, anterior shoulder, and posterior/lateral aspect of the humerus. Venous symptoms could include distal edema (especially after activity) and pain (described as a dull ache and non-specific) in same peripheral distributions. There are two different kinds of thoracic outlet, entrapment vs compressive and distinguishing between them is important. A patient with compressive TOS usually has poor posture and describes and insidious onset with no history of any trauma. The subclavian artery and brachial plexus may be subjected to mechanical compressions at one of the potential sites if a there is a presence of a cervical rib, abnormal first rib, transverse enlargement of C7, hypertrophy of the surrounding muscles, abnormal costocoracoid ligament, abnormalities of the clavicle, regional enlargements. In comparison, a patient with entrapment TOS usually has co-morbidity(ies) including cervical and/or shoulder trauma or may be related to long standing repetitive stress activities. This patient’s symptoms are usually delayed in relationship to the initial trauma and the pain is constant. Treatment to patients with entrapment TOS usually provokes their symptoms. Epidemiology: The incidence of TOS is between 50%-80% in women usually manifesting in their forties. Because of the two kinds of TOS, poor posture, people who adopt poor body mechanics especially sitting at a desk, and/or trauma to surrounding areas can predispose a person to TOS. There also seems to be a high correlation between worker compensated patients and outcomes of TOS treatment. Diagnosis:

• Neurovascular compression tests: Adson test (positive in 60% of TOS patients), Wright test (positive in 18%), McGowan-Velinsky test (positive in 38%), elevated arm stress test (EAST – positive in 68%)

• Positive for TOS on electromyography • Positive Doppler fluximetry (with dynamic tests post-operatively)


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Indications for Surgery in Neurogenic TOS: 1. Confirmed diagnosis based on history and physical examination. Does not require

objective findings, such as neuroelectric studies, arterial vascular studies, or angiograms. 2. All associated or differential diagnoses have been evaluated and treated. 3. Appropriate physical therapy has been tried for at least 3-6 months and has failed. 4. The patient is experiencing some degree of disability at work, recreation, sleep or

activities of daily living. Nonoperative vs. Operative Management: Surgery has been shown to be successful when conservative treatment of TOS has failed or when patients have too severe of symptoms to tolerate conservative treatment. TOS release should be performed only on people with non-disputed TOS (neurogenic, arterial, or venous forms), however objective diagnosed cases are rare. Therefore, most surgeries are done on people with disputed TOS. The most favorable results of treating TOS have been shown through conservative management. However, a study by Landry, GJ. et al (2001) stated that follow up data of 70 patients indicated that there were no significant difference between the patients that had surgery and the patients that were treated with non operative management. Another study by Toso, C et at (1999) stated that follow up data of 28 patients would chose to have TOS surgery again if symptoms were to reappear and 13 said to have had a poor outcome. However, this article also admitted that conservative treatment should always be tried first because most cases or TOS are due to muscle imbalance and poor posture. Most authors agree that strengthening and stretching exercises should be administered and surgery can be proposed when symptoms are too severe to be treated conservatively or after 6-12 months of unsuccessful conservative management. Surgical Procedure: There is no surgical procedure proven to be better than any other. These techniques include scalenotomy, scalenectomy, neurolysis, claviculectomy, and pectoralis minor release. Some researchers state that if a cervical rib is present, surgeons can either resect it or resect the first rib. If the surgeon chooses to resect the cervical rib, they can choose a supraclavicular approach. If they choose to remove the first rib, they can choose a transaxillary or transthoracic approach. If there a cervical rib is absent, then any of the three approaches (supraclavicular, transaxillary, and transthoracic) are available. Neurolysis, another surgical option, is considered easy to perform over C5, C6, and C7 nerves. C8 and T1 nerves are often covered by various tissues including the scalene minimus muscle in 25% of people, which must be removed. The scalenetomy procedure begins by retracting the C5 nerve medially and identifying the long thoracic nerve (LTN), which arises from C5, C6, and C7 nerve. Once this nerve is identified any or all of the three scalene muscles can be excised. The middle scalene is the most common scalene excised. Once a scalenectomy and neurolysis are complete, the operation can continue through the same incision with a first rib resection. Research, however, as shown that success rates for scalenectomies with and without rib resections is 70% indicating that there may not be need for a rib resection if scalenectomie(s) have occurred. Long-term results indicate that complete scalenectomies (all three scalene muscles) did not have a better success rate than subtotal or partial scalenectomies.


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Preoperative Rehabilitation: Preoperative rehab tends to be heavily performed in hopes of avoiding any form of surgery since most TOS can be corrected. Therefore, a preoperative protocol is intensive and individualized. Stage one – The goal in this stage is to decrease and control the patient’s symptoms. It is imperative in this stage that the patient and therapist identify activities, positions, and treatments that exacerbate and relieve the patient’s symptoms. Stage two – This stage is initiated once control and comfort has been achieved. In this stage tissues directly related to the TOS component can be addressed. This includes treating these tissues that are creating structural limitations of motion or compression. During this stage, treatment may exacerbate the patient’s symptoms, however, it should not last beyond the treatment session. This stage introduces techniques such as soft tissue mobilization. These manual techniques are to improve flexibility of involved tissues, restore normal resting lengths of musculotendonous units, and assist in restoring normal posture. This protocol includes joint mobilization of the acromioclavicular, sternoclavicular, and scapulothoracic joints, first rib, and cervical spine. In addition, deep massage and stretching of the pectoralis group and stretching of the scalene muscles should be performed. This is thought to potentially increase the size of the space and minimize compression of neurovascular structures. In addition, this stage should introduce postural awareness and correction as well as brachial plexus gliding and peripheral nerve mobilization to decrease neural tension. Stage three – This stage is when treatment gets intense. It involves all treatment techniques from stage two but now introduces conditioning and strengthening of the muscles necessary to maintain the postural correction. The home exercise program proposed by Walsh, M. (1994) includes scalene stretching, cervical protraction and retraction, diaphragmatic exercises, pectoralis stretching, and shoulder-circle exercises. Scalene stretching involves the anterior and medial scalene which is done preferable in supine to maximize cervical muscles relaxation to maximally benefit from the stretch. Cervical retraction is to assist with decreasing the patient’s forward head and rounded shoulder posture. For diaphragmatic exercises the patient rests in supine, arms at his/her side, takes an inspirational breath and exhales maximally using abdominal muscles to stabilize the inferior portion of the rib cage. Pecoralis stretching is obtained many ways. Many choose to place forearm against a doorway and stretch the pectoralis muscle as the patient steps through the doorway. The same stretch can be achieved by placing both hands on opposite walls of a corner while the patient leans into the corner. Shoulder-circle exercises are performed with the patient sitting, arms at his/her lap, and then forms large shoulder circles forward and backward to strengthen the scapulothoracic and involved structures in the patient’s TOS. Additional exercises may be given as needed.


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Post operative Rehabilitation: This post-operative rehabilitation protocol is for patients who have undergone scalenectomy and neurolysis. If the first rib has been excised than slight modifications may need to be made. Initially post operative rehab closely resembles pre operative with emphasis on wound care, edema control and scar management while incorporating range of motion (ROM) exercises and nerve gliding techniques. Early Care: Patients are seen in therapy day one after leaving the hospital. The first area of focus is on wound care and the patient may have a drain in the wound covered by Tegaderm. Patients are instructed to keep track of the amount of drainage and when there is less than 10 ml per 8 hours of 25 ml per 24 hours, the drain is removed. The drain site continues to be covered to further reduce the chance of infection. If the wound continues to drain a bandage is applied and the patient is instructed to keep sutures clean and dry. The patient is, however, allowed to shower and swim once drain sites are closed and wound has not drained for a few days. A pressure bandage should be applied to decrease edema and should be worn full time for the first 7-10 days post op, however can be removed temporarily if it interferes with cervical range of motion. Sutures are removed 7-10 days post operatively and a scar pad can be worn at night. The physical therapist can assist by educating the patient in edema control techniques as part of their home exercise program (HEP). Retrograde massage for the involved upper extremity can be performed. An arm sling should be worn for the first 2 weeks when walking around or riding in a car, but should be encouraged to keep their arm out of the sling and elevated on pillows when sitting or sleeping. Patients should sleep on their uninvolved side with a pillow supporting the involved side. Scar management begins 24-48 hours after sutures have been removed. PostoperativeDay 1 (week 1): ROM and nerve gliding exercises, review/education of cervical ROM, shoulder pendulum exercises and hand tendon gliding exercises should occur. Patients should be encouraged to use their uninvolved side. Gentle ROM, active, and active assisted ROM should be started as tolerated. Instruct the patient to perform these exercises holding the position for 5 seconds just before the point of pain or strain. These exercises should be done 3-4 times daily. Remember drain removal occurs at approximately 3-5 days. Day 8 (week 2): Sutures are removed and continue gliding exercises for neck and upper extremity. Day 15 (week 3): Scar massage and desensitization, possibly the introduction of weights. Day 22 (week 4): Phonophoresis to scar site, brachial plexus massage, and start strengthening exercises. This part of the treatment is very individualized depending largely on the patient’s pre operative activity level. Increases are applied to the program at least weekly while the patient monitors their pain. If patients are expecting to return to work, an ergonomic and body mechanic analysis may need to occur. This in combination with adequate strengthening are the most important to return to a job.


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Day 29 (week 5): Progress the strengthening exercises Day 36 (week 6): Ergonomic training, work-simulated activities, possibly a Functional Capacity Evaluation (FCE) for worker compensated patients. Day 43-83 (weeks 7-12): Work hardening exercises Therapy typically lasts 3 months with patients attending 2-3 times per week. A HEP is necessary from day one. Stretches should occur on a daily basis for at least 2 years because of scar contraction, which can occur for this duration. Occasionally patients return in 6-12 months because they do not keep up with their HEP. This course of therapy usually includes phonophoresis to reduce inflammation and scarring. Again, a thorough review of posture, stretching, and strengthening exercises needs to occur because TOS can usually be prevented. Precautions: Patients should not lift more than 5 pounds until 6 weeks post-operative. Therapist should not push patient through increased or new pain. If swelling occurs at surgical site, in the involved upper extremity or periscapular area, report immediately to surgeon or supervising physician. Report any increased heat, redness, marked increased pain or drainage from the surgical site, as well as any onset of headache, dizziness, numbness in hands, feet, groin, or low back pain that is new. Symptoms lasting longer than 2 hours would indicate a need for the therapist to modify the exercise program. Selected References: Landry GJ, Moneta GL, Taylor LM, Edwards JM, Porter JM. Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients. Journal of Vascular Surgery. 2001;33:312-319. Marinoni EC, Bonfiglio G, Boletti M, Passarelli O. Thoracic Outlet Syndrome: Proposed Protocol for Diagnosis and Treatment. Institute of Clinical Orthopaedics and Institute of Vascular Surgery, University of Milan. Pgs. 379-386. Sanders RJ, Hammond SL. Supraclavicular first rib resection and total scalenectomy: technique and results. Hand Clin. 2004;20:61-70. Toso C, Robert J, Berney T, Pugin F, Spiliopoulos A. Thoracic outlet syndrome: influence of personal history and surgical technique on long-term results. European Journal of Cardio-thoracic Surgery. 1999;16:44-47. Walsh, M.T. Therapist management of thoracic outlet syndrome. J Hand Therapy. 1994;7:131-144. Wishchuk JR, Dougherty CR. Therapy after thoracic outlet release. Hand Clin. 2004;20:87-90.


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