Eric Shamus, PhD, DPT, PT, CSCS, Kathy Swanick, DPT, PT, OCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Bekhterev disease
Bekhterev syndrome
Marie-Strümpell disease
Rheumatoid spondylitis
Spondylitis
Spondyloarthropathy
++
++
+++
PREFERRED PRACTICE PATTERNS3
++
4B: Impaired Posture
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation
4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders
++
PATIENT PRESENTATION
A 33-year-old female presents with complaints of low back pain with insidious onset and duration of over 3 months. She reports that her neck is also stiff, and driving a car has been difficult. She works for a company that provides computer technical support to many local businesses and needs to drive for her work. She has morning stiffness that generally improves with activity and exercise. There has also been a recent onset of swelling in the left knee and heel pain. There are times when the pain wakes her from sleep in the middle of the night; however, if she gets up and walks around or takes a hot shower, her pain is relieved enough to be able to go back to sleep.
She is referred to physical therapy by her rheumatologist, and has the results of several tests. Pulmonary function tests show decreased vital capacity and total lung capacity, although residual and functional residual lung volumes were increased. Hematology tests showed a mild normocytic anemia, and a normal white count. Erythrocyte sedimentation rate and alkaline and creatinine phosphatase were elevated. There was no rheumatoid factor present. Posture shows a flattening of the lumbar lordosis and a dorsal stooping posture with an accentuation of the thoracic kyphosis. There is tenderness over the spinous processes of the lumbar and thoracic vertebrae. A bony spur is palpated at the right heel at the proximal insertion of the plantar fascia. AROM is severely diminished lateral flexion of the spine, forward flexion and extension are decreased by 50%. Left knee ROM is decreased both actively and passively by 10 degrees.
++
++
Progressive inflammation of the spinal joints that leads to bone formation, natural fusion, and often increased kyphosis of the thoracic spine.
Ankylosing means fusion; spondylitis means inflammation of the spine.
+++
Essentials of Diagnosis4
++
+++
General Considerations
++
Begins with intermittent low back pain
Pain and stiffness at rest or sleep
Improvement with low levels of activity
May have rapid and severe onset
Secondary problems include
++
Disease onset between ages 20 and 40 years
Male-to-female ratio: 10:1
Caucasians afflicted more frequently than African Americans
++
SIGNS AND SYMPTOMS
Fatigue
Decreased range of motion and joint play
Intermittent back pain
Eye inflammation
Heel pain
Hip pain and stiffness
Joint pain and swelling in the shoulders, knees, and ankles
Loss of appetite
Slight fever
Weight loss
Morning stiffness
Acute painful flare-ups and chronic, persistent pain
Thoracic and Pulmonary involvement
++
+++
Functional Implications
++
++
+++
Possible Contributing Causes
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
++
Complete blood count (CBC)
ESR
HLA-B27 antigen, genetic marker
No single blood test
Negative serologic tests for rheumatoid factor
+++
FINDINGS AND INTERPRETATION
++
++
NSAIDs
TNF-inhibitors
Corticosteroids
Cytotoxic drugs
Biologic medications
++
++
++
++
Education in gentle range of motion to maintain mobility
Flexibility and stability strengthening exercises to decrease stress on the joints
Education on joint protection
Postural training
Warm shower or heat to increase mobility
++
Patient will be able to.
Be independent with home exercise program.
Have decreased pain and be able to perform household activities, such as cleaning and laundry.
Have improved functional level sufficient for grocery shopping.
++
Disease progression is not specific; joints may become fused as disease becomes more severe.
Symptoms may be intermittent.
Patients function well until severe progression of joint fusion in the spine and hips occurs.
++
Arie J. Van Duijn, EdD, MSc, PT, OCS, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERN
++
4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders1
++
PATIENT PRESENTATION
A 45-year-old male presents with pain and stiffness in the left cervical region. He reports waking up with this condition 3 days ago. The pain is located along the left C3-4 and C4-5 spinal segments, and is aggravated by looking over the left shoulder and looking up. Increased muscle tone is present in the left levator scapula and upper trapezius muscles. No pain, numbness, or tingling in the upper extremities is noted, and neurological examination is normal. Passive intervertebral motion (PIVM) testing reveals restriction in downglide mobility of the left C3-4 facet joint. Quadrant testing is positive when combining extension, left side bending, and left rotation. Point tenderness is noted upon palpation of the left C3-4 facet joint.
++
++
++
++
+++
Essentials of Diagnosis
++
Diagnosis made by clinical examination
Reproduction of symptoms when joint in closed-packed position (combination of extension, side bending, and rotation toward involved side)
+++
General Considerations
++
++
++
SIGNS AND SYMPTOMS
Pain in cervical area that can be reproduced mechanically
Unilateral or bilateral referred pain in upper extremities possible in a nonradicular pattern
Active range of motion (AROM) limited in a capsular pattern; rotation and side bending limited in same direction
Cervical segmental hypomobility may be present in capsular pattern
Can be associated with forward-head posture
+++
Functional Implications
++
+++
Possible Contributing Causes
++
+++
Differential Diagnosis
++
Malignant spinal tumor or metastasis
Peripheral nerve impairment
Radiculopathy
Referred pain from visceral structures
Systematic autoimmune diseases (RA, Reiter’s, etc.)
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
Not necessary in most cases; only with persistent symptoms that do not respond to conservative management or presence of red/yellow flags.
MRI helps visualize compressed or inflamed nerve root/disc pathology in diagnosis2
X-ray/Plain-film radiograph helps assess alignment, fractures, stability (flexion/extension radiograph)3
CT scan to show herniation compressing the spinal canal or nerves3
Electrodiagnostic/Nerve conduction testing can help determine a specific impaired nerve function4
Doppler ultrasound to examine vascular function
++
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
++
++
REFERRALS/ADMITTANCE
For imaging
For surgical consult if myelopathy suspected (lumbar radiculopathy)
For imaging and medical consult if disease suspected
If vascular insufficiency suspected
++
Hypomobile cervical spine
Weakness of deep neck flexors and upper-extremity stabilizers
Shortening of upper trapezius, levator scapulae, pectoral muscles
Postural changes
Inability to rotate head
++
Cervical spine AROM
Sharp–Purser: Atlantoaxial instability
Cervical passive intervertebral motion testing
Sub-cranial translation instability testing
Passive physiological intervertebral mobility testing (PPIVM)5
Upper-extremity screening examination
Postural examination
Muscle length testing, including upper trapezius, levator scapulae, pectoral muscles
Upper limb nerve tension test6
Deep neck-flexor endurance test
Upper-extremity neurological screen (dermatome, myotome, reflexes)
++
Joint mobilization/manipulation
Postural correction
Initiate stabilization exercises after normalizing ROM (deep neck flexors)
Stretching exercises and myofascial mobilization for shortened musculature
Modalities for short-term pain control
++
Patient will be able to
Sit with a cervicothoracic spine posture for more than 30 minutes with 0 out of 10 pain rating.
Sit at work station and perform computer work for 45 minutes with 0 out of 10 pain rating.
Rotate cervical spine 80 degrees to look over shoulder when driving without pain.
++
++
1. +
The American Physical Therapy Association. Pattern 4F: impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders. Interactive Guide to Physical Therapist Practice 2003. doi: 10.2522/ptguide.3.1_6
http://guidetoptpractice.apta.org/content/1/SEC13.extract. Accessed May 21, 2014.
+++
ADDITIONAL REFERENCES
+
Fritz
JM, Cleland
JA, Childs
JD. Subgrouping patients with low back pain: Evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37(6):290–302.
[PubMed: 17612355]
CrossRef +
Liebenson
C. Rehabilitation of the Spine. Baltimore MD: Lippincott, Williams & Wilkins; 2007.
+
Olsen
KA. Manual Therapy of the Spine. St. Louis, MI: Saunders Elsevier; 2009.
Eric J. Chaconas, DPT, PT, FAAOMPT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Herniated intervertebral disk
Prolapsed intervertebral disk
Slipped disk
Ruptured disk
Herniated nucleus pulposus
++
719.48 Pain in joint involving other specified sites
721.1 Cervical spondylosis with myelopathy
722.0 Displacement of cervical intervertebral disc without myelopathy
722.4 Degeneration of cervical intervertebral disc
722.71 Intervertebral disc disorder with myelopathy cervical region
++
M47.12 Other spondylosis with myelopathy, cervical region
M50.00 Cervical disc disorder with myelopathy, unspecified cervical region
M50.30 Other cervical disc degeneration, unspecified cervical region
+++
PREFERRED PRACTICE PATTERN
++
4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders1
++
PATIENT PRESENTATION
A 57-year-old female presents with reports of left-sided neck, shoulder, and arm pain persisting for the past eight months. She does not recall a specific injury and reports a gradual onset of pain. Symptoms are described as aching with burning and numbness into the arm and hand. She works as a medical billing specialist and reports increased symptoms after sitting at her desk for over an hour and driving her car for extended periods of time. Cervical left side bending and rotation movements increase arm pain and manual distraction provides symptom relief. Significant forward-head posture is noted along with weakness of the bilateral rhomboids, middle trapezius and serratus anterior. Diminished sensation is noted over the left thumb along with weakness of the left wrist extensors.
++
Any disorder that affects the spinal nerve roots
Lateral cervical spine nerve root compression
Gradual or acute onset secondary to intervertebral disc or osteophyte formation in the intervertebral foramen1
++
+++
Essentials of Diagnosis
++
+++
General Considerations
++
++
++
SIGNS AND SYMPTOMS
Neck, shoulder, upper-extremity pain, and parasthesia often radiating to hand1
Pain in cervical spine worsens with cervical extension, side bending, and rotation to the involved side1
Diminished sensation, motor control, and reflexes in the distribution of the involved nerve1
+++
Functional Implications
++
Difficulty sustaining sitting postures secondary to neck and arm pain
Inability to sleep
Weakness with upper-extremity lifting
Loss of movement or feeling in upper extremity
Difficulty with neck movements, as with driving, secondary to pain
+++
Possible Contributing Causes
++
Forward-head or rounded-shoulder posture due to tight pectoralis, weak periscapular, deep neck-flexor muscles
Prolonged extension or position of cervical side bending toward impaired nerve
Facet hypertrophy
Size of spinal canal; can be congenital
+++
Differential Diagnosis
++
Carpal tunnel syndrome
Chiari malformation
Degenerative disk disease
Peripheral nerve impairment
Rhomboid/trapezius spams
Shoulder pathology with radiating pain pattern
Spinal tumor
Thoracic outlet syndrome
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
MRI helps to visualize compressed or inflamed nerve root in diagnosis2
X-ray/Plain-film radiograph helpful if osteophyte located in intervertebral foramen3
CT scan to show herniation compressing the spinal canal/nerves3
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
++
++
++
REFERRALS/ADMITTANCE
To hospital for imaging
To physician for surgical consult if myelopathy suspected
To hospital for imaging and medical consult if sinister disease suspected
Decompression2
Diskectomy2
Fusion2
Hemilaminectomy2
Laminectomy2
Laser diskectomy2
Microdisectomy2
Percutaneous diskectomy2
To physician for corticosteroid injection if condition does not improve
To physician for anti-inflammatory medication
++
++
Restricted mobility of the upper- or mid-thoracic spine and subcranial spine
Hypermobile mid-cervical spine
Tight pectoralis major and minor
Weakness of longus colli and longus capitis
Weakness of periscapular muscles
++
Cervical spine AROM
Sharp–Purser: Atlantoaxial instability
Cervical passive intervertebral motion testing
Sub-cranial translation instability testing
Passive physiological intervertebral mobility testing (PPIVM)
Upper-extremity screening examination
Postural examination
Muscle length testing, including upper trapezius, levator scapulae, pectoral muscles
Upper limb nerve tension test
Neck Disability Index (NDI)
Deep neck-flexor endurance test
Upper-extremity neurological screen (dermatome, myotome, reflexes)
++
Rest
Joint manipulation to the thoracic and upper-cervical spine
Cervical distraction and traction to relieve nerve compression
Cranio-cervical flexion exercises
Periscapular strengthening
Address pain
Address hypertonicity
Address muscle weakness
Deep neck-flexor training
Strengthening of lower/middle trapezius, rhomboids, rotator cuff
Serratus anterior, latissimus dorsi
++
Patient will be able to
Sit with a neutral cervical and thoracic spine posture for >30 minutes with 0/10 pain rating.
Patient will be able to sit at work station and perform computer work for 45 minutes with 0/10 pain rating.
Patient will be able to rotate cervical spine 70 degrees to talk on phone with 0/10 pain rating in the neck or arm.
++
++
++
1. +
American Physical Therapy Association. Pattern 4E: impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice by American Physical Therapy Association. 2003. ISBN: 978-1-887759-87-8. doi : 10.2522/ptguide.978-1-931369-64-0.
+++
ADDITIONAL REFERENCES
+
Prentice
WE, Quillen
WS, Underwood
F. Principles of electrophysiologic evaluation and testing. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation, 4e.
http://www.accessphysiotherapy.com/content/8137409, Accessed January 2, 2013:Chapter 8.
+
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. 2003;28(1):52–62.
[PubMed: 12544957]
CrossRef
Arie J. Van Duijn, EdD, MSc, PT, OCS, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
M48.00 Spinal stenosis, site unspecified
M48.02 Spinal stenosis, cervical region
+++
PREFERRED PRACTICE PATTERN
++
4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders1
++
PATIENT PRESENTATION
A 72-year-old male presents with gradually increasing complaints of diffuse neck pain, cramping and pain in both the upper and lower extremities, and occasional loss of bladder control. These symptoms are aggravated with cervical extension and relieved with cervical flexion. A pronounced forward-head posture is noted, and there is a significant loss of active and passive cervical range of motion in all directions. Neurological examination revealed increased muscle tone bilaterally in the biceps brachii and gastrocnemius muscles with brisk deep tendon reflexes. A positive Babinski reflex was present bilaterally. MRI evaluation revealed narrowing of the central spinal canal in the lower cervical region, along with loss of disk height and significant osteophyte formation in this area.
++
++
Common, degenerative spinal condition
Associated with narrowing of the spinal canal (central stenosis) or foraminal canals (lateral stenosis)
Caused by degenerative changes in intervertebral disks and facet joints
Can result in spinal cord compression or nerve root compression
+++
Essentials of Diagnosis
++
Causes neurogenic claudication, with pain, cramping, and paresthesias in the upper extremity and lower extremity aggravated by cervical extension, relieved by cervical flexion
Diagnosis made by clinical examination
Differentiation between vascular and neurologic claudication
Reproduction of symptoms in specific postures and activities
+++
General Considerations
++
++
++
SIGNS AND SYMPTOMS
Bilateral leg pain
Unilateral or bilateral upper limb pain and myelopathy with cervical stenosis
Pain worse with walking, relieved by sitting
Can be with or without neck pain
Altered sensation, motor control, and reflexes in the distribution of the involved nerve roots
+++
Functional Implications
++
Difficulty with walking long distances
Difficulty with standing activities
Possible bowel or bladder dysfunction with cervical stenosis
Difficulty looking up
Difficulty reaching overhead, painting overhead
+++
Possible Contributing Causes
++
+++
Differential Diagnosis
++
++
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
MRI helps to visualize compressed or inflamed nerve root in diagnosis.3
X-ray/Plain-film radiograph helpful if osteophyte located in intervertebral foramen.4
CT scan to show herniation compressing the spinal canal/nerves.4
++
REFERRALS/ADMITTANCE
To hospital for imaging
To physician for surgical consult if myelopathy suspected
Fusion3
Decompression3
Laminectomy3
To hospital for imaging and medical consult if disease suspected
To vascular surgeon if suspected vascular insufficiency
++
Hypomobile cervical spine
Weakness of core stabilizing muscles
Inability to stand/walk for prolonged time
Inability to look for prolonged time (visual fatigue)
++
Cervical spine AROM
Sharp–Purser: Atlantoaxial instability
Cervical passive intervertebral motion testing
Sub-cranial translation instability testing
Passive physiological intervertebral mobility testing (PPIVM)
Neck Disability Index (NDI)
Postural examination
Muscle length testing, including upper trapezius, levator scapulae, pectoral muscles
Deep neck-flexor endurance test
Upper-extremity neurological screen (dermatome, myotome, reflexes)
Physical examination
++
Joint manipulation to the thoracic and lumbar spine when joint hypomobility is present.
Specific exercises in flexion when pain centralizes with repeated movement/posture into flexion
Lumbar stabilization exercises to address core stability
Stretching exercises and myofascial mobilization for shortened musculature
Unweighted treadmill walking
Aquatic exercise
Mechanical traction in flexion position
++
++
++
++
Variable: Multimodal conservative management, including progressive exercise, unweighted walking, manual therapy show positive outcomes
Severe cases of stenosis may require surgical intervention
++
1. +
American Physical Therapy Association. Pattern 4E: impaired joint mobility, motor function, muscle performance, and range of motion asssociated with localized inflammation. Interactive Guide to Physical Therapist Practice by American Physical Therapy Association. 2003. ISBN: 978-1-887759-87-8. doi : 10.2522/ptguide. 978-1-931369-64-0.
+++
ADDITIONAL REFERENCES
+
Fritz
JM, Cleland
JA, Childs
JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37(6):290–302.
[PubMed: 17612355]
CrossRef +
Liebenson
C. Rehabilitation of the Spine. Baltimore, MD: Lippincott, Williams & Wilkins; 2007.
+
Olsen
KA. Manual Therapy of the Spine. St. Louis, MI: Saunders Elsevier; 2009.
Eric Shamus, PhD, DPT, PT, CSCS, Eric J. Chaconas, DPT, PT, FAAOMPT
++
+++
CONDITION/DISORDER SYNONYM
++
++
738.4 Acquired spondylolisthesis
756.12 Spondylolisthesis congenital
805.02 Closed fracture of second cervical vertebra
++
M43.10 Spondylolisthesis, site unspecified
Q76.2 Congenital spondylolisthesis
S12.100A Unspecified displaced fracture of second cervical vertebra, initial encounter for closed fracture
S12.101A Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation1
++
PATIENT PRESENTATION
A 50-year-old man presents with a gradual onset of neck pain for 2 years. Plain-film radiographs reveal a low-grade spondylolisthesis of the C5 vertebrae. He reports the symptoms are worse while lying supine, cervical backward bending, and prolonged sitting postures. A palpable step is noted in the mid cervical spine along with increased paraspinal muscle tone. Neurologic signs and instability testing are all negative. Decreased motor control and endurance of the deep neck flexors are noted along with decreased joint mobility in the upper thoracic spine.
++
Anterior (forward) translation of a vertebra
Fracture of the pedicles on the vertebra below
Slipping of the vertebra in relationship to the vertebra below
Neurogenic claudication
Fracture widens at the pars
Hangman’s fracture
C2 vertebra anterior translated on C3 with fracture of C2 pedicles
+++
Essentials of Diagnosis
++
Made by X-ray
May be acquired or congenital
Clinical examination may find step deformity
Dermatome/myotome pattern
Low-grade isthmic spondylolisthesis: less than 50% displacement
High-grade isthmic spondylolisthesis: greater than 50% displacement
Four grades2
Grade 1: 0% to 25% slippage
Grade 2: 25% to 50% slippage
Grade 3: 50% to 75% slippage
Grade 4: 75% to 100% slippage
Spondylolysis: Fracture without displacement
++
+++
General Considerations
++
++
++
SIGNS AND SYMPTOMS
Cervical, shoulder, arm, and upper extremity pain and paresthesia, often radiating into the lower extremities if central cord involvement
Constricted pupil (Horner sign)
Stiffness along spine
Headaches
Pain in cervical spine worsens with extension
Diminished sensation, motor control, and reflexes in the distribution of the involved nerve
Neurogenic claudication
++
+++
Functional Implications
++
Difficulty sustaining standing postures secondary to neck and arm pain
Inability to sleep flat on the back without a pillow
Weakness with lifting
Loss of movement or feeling in the upper extremity
Difficulty with movements secondary to pain, especially reaching overhead
Limited sports participation
+++
Possible Contributing Causes
++
Forceful extension from hit under the chin (sports)
Congenital
Car accident, hit from rear
Hyperextension of the cervical spine
Suicidal hanging
Increased cervical lordosis posture
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
MRI helpful in diagnosis to visualize compressed or inflamed nerve root3
X-ray/Plain-film radiograph to see vertebra position (Scottie dog collar)2
CT scan to show herniation compressing the spinal canal or nerves4
Electrodiagnostic/nerve conduction testing can help determine a specific impaired nerve function5
++
+++
FINDINGS AND INTERPRETATION
++
++
++
REFERRALS/ADMITTANCE
For imaging
For surgical consult if myelopathy is suspected
Fusion3
Decompression3
Laminectomy3
Hemilaminectomy3
For corticosteroid injection
For anti-inflammatory medication
For halo vest traction device, cervical bracing
++
++
Cervical spine AROM
Sharp–Purser: Atlantoaxial instability
Cervical passive intervertebral motion testing
Subcranial translation instability testing
Passive physiologic intervertebral mobility testing (PPIVM)
Upper-extremity screening examination
Postural examination
Muscle length testing, including the upper trapezius, levator scapulae, and pectoral muscles
Upper limb nerve tension test
Deep neck flexor endurance test
Upper-extremity neurologic screen (dermatome, myotome, reflexes)
Neck Disability Index (NDI)
++
Rest
Bracing
Address pain
Electrical stimulation
Heat/Ice6
Address hypertonicity
Address muscle weakness
++
++
Patient will be able to
Sit with neutral cervical spine posture for >30 minutes with 0/10 pain rating.
Stand at work station and perform computer work for 45 minutes with 0/10 pain rating.
Rotate cervical spine 75 degrees to look over shoulder while driving the car with 0/10 pain rating.
++
Fair to good, depending on severity of vertebral translation, amount of nerve root compression, and upper/lower extremity impairments.
Possible death from asphyxia.
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_5. Accessed March 1, 2013.
+++
ADDITIONAL REFERENCES
+
Curtis
C, d’Hemecourt
P. Diagnosis and management of back pain in adolescents. Adolesc Med State Art Rev. 2007;18:140–164.
[PubMed: 18605395]
+
Prentice
WE, Quillen
WS, Underwood
F. Chapter 8. Principles of electrophysiologic evaluation and testing. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed.
http://www.accessphysiotherapy.com/content/8137409. Accessed January 21, 2013.
+
Wainner
RS, Fritz
JM, Irrgang
JJ
et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52–62. Accessed January 21, 2013.
[PubMed: 12544957]
CrossRef
Eric Shamus, PhD, DPT, PT, CSCS, Eric J. Chaconas, DPT, PT, FAAOMPT
++
+++
CONDITION/DISORDER SYNONYM
++
++
++
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation1
++
PATIENT PRESENTATION
A 29-year-old man presents with acute neck pain after trauma to the cervical spine during soccer practice. He was immobilized with a rigid cervical collar for 6 weeks after advanced imaging confirmed a pars defect at the C4 level. Currently, he presents with guarded movement in all directions and increased tone and tenderness in the cervical spine musculature. Significant weakness is noted in the longus colli, longus capitis, middle trapezius, and rhomboids. Neurological examination is negative, and the patient’s goal is to return to playing soccer.
++
+++
Essentials of Diagnosis
++
+++
General Considerations
++
++
++
SIGNS AND SYMPTOMS
Pain in the cervical spine, shoulder, arm, upper extremity
Stiffness along the spine
Headaches
Pain in the cervical spine worsens with extension
++
+++
Functional Implications
++
Difficulty sustaining standing postures secondary to neck and arm pain
Inability to sleep flat on the back without a pillow
Difficulty with movements (reaching overhead) secondary to pain
Limit sports participation
+++
Possible Contributing Causes
++
Forceful extension from hit under the chin (sports)
Congenital
Car accident, hit from rear
Hyperextension of the cervical spine
Increased cervical lordosis posture
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
MRI helps to visualize compressed or inflamed nerve root in diagnosis2
X-ray/Plain-film radiograph to see vertebra position3
CT scan to show herniation compressing the spinal canal/nerves3
Electrodiagnostic/nerve conduction testing can help determine a specific impaired nerve function4
+++
FINDINGS AND INTERPRETATION
++
++
++
REFERRALS/ADMITTANCE
For imaging
For surgical consult if myelopathy is suspected
Fusion2
Decompression2
Laminectomy2
Hemilaminectomy2
For corticosteroid injection, anti-inflammatory medication
For halo vest traction device, cervical bracing
++
++
Cervical spine AROM
Sharp–Purser: Atlantoaxial instability
Cervical passive intervertebral motion testing
Subcranial translation instability testing
Passive physiologic intervertebral mobility testing (PPIVM)5
Upper-extremity screening examination
Neck Disability Index (NDI)
Postural examination
Muscle length testing, including the upper trapezius, levator scapulae, pectoral muscles
Upper limb nerve tension test6
Deep neck flexor endurance test
Upper-extremity neurologic screen (dermatome, myotome, reflexes)
++
++
++
Rest
Bracing
Address Pain
Electrical stimulation
Heat/Ice5
Address hypertonicity
Address muscle weakness
++
Patient will be able to
Sit with neutral cervical spine posture for >30 minutes with 0 out of 10 pain rating.
Stand at work station and perform computer work for 45 minutes with 0 out of 10 pain rating.
Rotate cervical spine 75 degrees so as to look over the shoulder while driving the car with 0 out of 10 pain rating.
++
Fair to good, depending on severity of vertebral translation, amount of nerve-root compression, and upper/lower-extremity impairments.
++
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.978-1-931369-64-0. Online February 28, 2012. Accessed April 28, 2013.
+++
ADDITIONAL REFERENCES
+
Prentice
WE, Quillen
WS, Underwood
F. Chapter 8. Principles of electrophysiologic evaluation and testing. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed.
http://www.accessphysiotherapy.com/content/8137409. Accessed April 28, 2013.
+
Wainner
RS, Fritz
JM, Irrgang
JJ
et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52–62. [PMID: 12544957]
[PubMed: 12544957]
CrossRef
Eric Shamus, PhD, DPT, PT, CSCS, Eric J. Chaconas, DPT, PT, FAAOMPT
++
+++
CONDITION/DISORDER SYNONYMS
++
Cervical osteoarthritis
Spinal osteoarthritis
++
721 Spondylosis and allied disorders
721.0 Cervical spondylosis without myelopathy
721.1 Cervical spondylosis with myelopathy
721.9 Spondylosis of unspecified site
721.90 Spondylosis of unspecified site without myelopathy
721.91 Spondylosis of unspecified site with myelopathy
++
M47.12 Other spondylosis with myelopathy, cervical region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M47.819 Spondylosis without myelopathy or radiculopathy, site unspecified
++
++
+++
PREFERRED PRACTICE PATTERNS
++
4B: Impaired Posture1
4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Format Range of Motion Associated with Connective Tissue Dysfunction2
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation3
++
PATIENT PRESENTATION
A 72-year-old woman presents with neck and bilateral upper extremity pain. She reports worsening of symptoms over the past 2 months and increased numbness into the bilateral hands. Magnetic resonance imaging (MRI) reveals stenosis of the spinal canal at the C6 level along with myelopathy. Diminished sensation is noted in the bilateral thumbs along with weakness of the wrist extensors. Balance impairments are noted, and the patient reports increasing difficulty with ambulation.
++
Osteoarthritis of the cervical spine
Chronic degeneration
Progressive arthritis of the cervical spinal joints
As space between the vertebrae decreases, there may be compression onto the nerve roots
Arthritis can be central- or lateral-foramen based
Pain, paresthesia, and weakness in the upper extremities, can affect lower extremities if central and severe
Pressure on the nerve root can cause radiculopathy
+++
Essentials of Diagnosis
++
X-ray
Acute painful flare-ups, chronic persistent pain
Relief with nonsteroidal anti-inflammatory drugs (NSAIDs)
Morning stiffness
+++
General Considerations
++
Begins with intermittent pain
Pain and stiffness at rest/sleep
Improved with low-level activity
May have rapid and severe onset
Vertebrobasilar insufficiency is secondary problem
++
++
SIGNS AND SYMPTOMS
Fatigue
Stiffness
Heaviness in the upper extremities
Loss of range of motion and joint play
Intermittent pain, increases with weight bearing
Paresthesia
Tingling sensation in the upper extremity
Diminished reflexes
Lower motor neuron dysfunction
Muscle weakness in the arm
Radiculopathy
Characteristics of the different syndromes of cervical spondylotic myelopathy4
++
++
+++
Functional Implications
++
Limited mobility in cervical motion
Difficulty looking over the shoulder while driving
May have difficulty washing hair at hair dresser due to cervical spine extension
Increased symptoms with increased weight-bearing
Aerobic endurance limitation
+++
Possible Contributing Causes
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
FINDINGS AND INTERPRETATION
++
++
++
++
++
Cervical spine AROM
Sharp–Purser: Atlantoaxial instability
Cervical passive intervertebral motion testing
Subcranial translation instability testing
Passive physiologic intervertebral mobility testing (PPIVM)5
Upper-extremity screening examination
Postural examination
Neck Disability Index (NDI)
Muscle length testing, including the upper trapezius, levator scapulae, and pectoral muscles
Upper limb nerve tension test6
Deep neck flexor endurance test
Upper-extremity neurological screen (dermatome, myotome, reflexes)
++
++
Education in gentle range of motion to maintain mobility
Exercise: Flexibility and stability strengthening to decrease stress on the joints
Joint protection education
Postural training
Joint manipulation to the thoracic and upper cervical spine
Cervical distraction and traction to relieve nerve compression
Craniocervical flexion exercises
Periscapular strengthening
Address Pain
Address hypertonicity
Address muscle weakness
Deep neck flexor training
Strengthening of the lower/middle trapezius, rhomboids, rotator cuff
Serratus anterior, latissimus dorsi
Heat or warm shower to increase mobility
++
Patient will
Be independent with home exercise program.
Be have decreased pain to perform household activities such as cleaning and laundry.
Have improved functional level to look over the shoulder while driving.
++
Disease progression is not specific; joints may become limited and have increased compression as disease becomes more severe.
Symptoms may be intermittent.
Patients function well until severe progression of joint mobility.
++
1. +
The American Physical Therapy Association. Pattern 4B: Impaired posture. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_2. Online February 28, 2012. Accessed April 1, 2013.
2. +
The American Physical Therapy Association. Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_4. Online February 28, 2012. Accessed April 1, 2013.
3. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide. 978-1-931369-64-0. Online February 28, 2012. Accessed April 1, 2013.
6. +
Hamilton
N, Weimar
W, Luttgens
K. Chapter 3. The Musculoskeletal System: The Musculature. In:Hamilton
N, Weimar
W, Luttgens
K Kinesiology: Scientific Basis of Human Motion. New York, NY: McGraw-Hill; 2008.
http://www.accessphysiotherapy.com/abstract/6150358#6150373. Accessed April 24, 2013.
+++
ADDITIONAL REFERENCES
+
Dutton
M. Pattern 4D: Impaired joint mobility, motor function, muscle performance, and format range of motion associated with connective tissue dysfunction. In:Dutton
M Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd ed. New York, NY: McGraw-Hill; 2012.
http://www.accessphysiotherapy.com/content/55592048. Accessed April 24, 2013.
+
Friedenberg
ZB, Miller
WT. Degenerative disc disease of the cervical spine. J Bone Joint Surg. 1963;45:1171–1178.
[PubMed: 14077981]
+
Jeffreys
E. Cervical spondylosis. In:Jeffreys
E Disorders of the Cervical Spine. Boston, MA: Butterworths. 1980:90–106.
http://www.spondylitis.org. Accessed April 14, 2013.
Elizabeth R. Northrop, DPT, PT, Cynthia E. Neville, DPT, PT, WCS
++
+++
CONDITION/DISORDER SYNONYM
++
++
724.7 Disorders of coccyx
724.70 Unspecified disorder of coccyx
724.71 Hypermobility of coccyx
724.79 Other disorders of coccyx
839.41 Closed dislocation, coccyx
839.42 Closed dislocation, sacrum
847.3 Sprain of sacrum
847.4 Sprain of coccyx
++
M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
M53.3 Sacrococcygeal disorders, not elsewhere classified
S33.2XXA Dislocation of sacroiliac and sacrococcygeal joint, initial encounter
S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter
+++
PREFERRED PRACTICE PATTERNS1
++
4B: Impaired Posture
4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation
4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture
++
PATIENT PRESENTATION
A 25-year-old woman delivered her first baby vaginally. She had epidural anesthesia during the delivery. During the delivery, she heard a loud “pop” noise. After the epidural wore off, she felt a severe pain in her rear end. She was unable to sit on the edge of the hospital bed and had severe pain when she attempted to sit in a chair.
++
++
++
+++
General Considerations
++
Consider sacroiliac (SI) joint as potential cause of pain
Ask patient about the history of falls; distant history can contribute to coccydynia
Occupations requiring prolonged sitting may contribute to coccydynia
Pain may be referred from muscles, including the obturator internus, levator ani, and gluteus maximus
++
Five times more common in women than in men
Mean age of onset is 40 years
Three times more common in obese patients
++
SIGNS AND SYMPTOMS
Pain in sitting position
Pain with transition from sitting to standing
Pain with standing, walking, forward flexion
Pain with defecation, coughing
Increased pain during menstruation
Inflammation
Poor sitting posture
Frequent shifts in sitting position, sitting down carefully
Luxation, hypermobility, hypomobility of the coccyx
+++
Functional Implications
++
Difficulty sitting, impacting ability to perform work and daily activities
Difficulty or pain with defecation
+++
Possible Contributing Causes
++
Vaginal delivery
Postpartum
Direct trauma from fracture, fall, childbirth
Poor sitting posture
Prolonged sitting
Anorectal infection
Levator ani spasm
Trigger points of obturator internus, levator ani, or gluteus maximus
Overuse of levator ani
Neoplasm
Pelvic asymmetry
Stretch or rupture of sacrococcygeal ligaments
Soft-tissue damage
+++
Differential Diagnosis
++
Sacral chordoma
Tarlov cyst
Pilonidal cyst
SI joint pain
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
++
Muscle relaxants
Oral analgesics
Oral corticosteroids
++
++
++
++
Palpation and mobility of the coccyx
Palpate the coccyx externally with single digit; attempt to move it 20 to 30 degrees.
Patients with coccydynia often have pain with movement; otherwise, movement should be pain free.
Assessment of the pelvic floor muscle
Palpation of the coccygeus, levator ani, obturator internus, and gluteus maximus for trigger points
Posture assessment
Assessment of pelvic girdle with pain provocation test
++
++
++
Seating adaptation: Coccyx cut-out wedge cushion (“donut” cushion)
Postural instruction
Education on normal defecation, to avoid constipation
Education on stress management and relaxation for patients with anxiety
Coccyx manipulation, sacrococcygeal joint manipulation or mobilization
Joint mobilizations to address hypomobility of the SI joint, lumbar, hip, or pubic symphysis dysfunction
Myofascial treatment to the coccygeus, levator ani, obturator internus, gluteus maximus, piriformis
Transvaginal or transrectal myofascial release
Vaginal or rectal electrical stimulation
Coccyx taping
Pelvic floor muscle exercise and training
Contraction
Relaxation, “bulging”
Motor control
Endurance
Power
Surface electromyography (sEMG) biofeedback for down-training of pelvic floor muscles
Exercises to address biomechanical dysfunction of the SI joint
++
Patients will be able to
Demonstrate proper posture to reduce pain and prevent reinjury of the coccyx.
Perform sit-to-stand transfers independently without increased pain.
Increase sitting tolerance to ____ minutes to be able to drive, ride in car, perform desk work.
Demonstrate independence with home exercise program, promoting relaxation and awareness of the pelvic floor muscle for long-term self-management.
++
Patients with normal coccyx mobility have 43% success rate with conservative treatment.2
Patients with immobile coccyx have 16% success rate with conservative treatment.2
Patients with hypermobility or subluxation of the coccyx have 85% success rate with combined manipulation and steroid/anesthetic injection.2
++
1. +
The American Physical Therapy Association. Interactive Guide to Physical Therapist Practice. Alexandria,
VA: The American Physical Therapy Association; 2003.
http://guidetoptpractice.apta.org/. Accessed June 21, 2013.
+++
ADDITIONAL REFERENCES
Ariel Diana Schumer, DPT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Acquired torticollis
Adult torticollis
Anterocollis
Dystonia
Focal dystonia
Laterocollis
Retrocollis
Spasmodic torticollis
Torticollis
++
++
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation
++
PATIENT PRESENTATION
Patient is a 66-year-old woman who has complaints over the last 2 years of neck pain and a pulling to the right side. Over the last year, she has had head tremors. She has tried Botox injections, which gave her temporary relief. Her friend gave her a cervical collar to wear and feels that if she does not wear it her head falls to the side. Past medical history: Severe whiplash injury 3 years ago due to a car accident.
++
Dystonia is a condition characterized by involuntary intermittent or prolonged muscular contractions (e.g., twisting, jerky, or repetitive movements) that may cause abnormal postures and movements.
Dystonia may be generalized or focal.
Cervical dystonia (CD) is the most common focal dystonia.
CD is commonly referred to as spasmodic torticollis, which may be misleading.
Spasmodic describes movements that are intermittent or clonic and tremulous, though some patients with CD present with prolonged contractions.
Torticollis implies rotary impairment, though patients with CD often present with combined postures associated with flexion, extension, and side-bending.
Further classification may be based on the head position or movement.1
Forward tilt is called anterocollis.
Backward tilt is called retrocollis.
Left or right tilt is called laterocollis.
Moving from side to side is called rotational spasmodic torticollis.
Turning and shaking of the head is called mixed torticollis.
++
++
++
+++
Essentials of Diagnosis
++
+++
General Considerations
++
Most cases develop in adulthood.
May begin in the neck and progress to the shoulders, usually stabilizes after a few years.
A similar musculoskeletal condition during infancy is called congenital muscular torticollis.
Patients with CD can show signs of self-consciousness and depression.
++
Incidence of CD is 8.9 per 100,000 people
Occurrence in men to women ranges from 1 man to 1.4 to 2.2 women (1:1.4–2.2)
Mean age of onset is 39.2 years for men and 42.9 years for women2
Approximately 90% of cases are idiopathic and 10% to 20% are from a defined cause.
++
+++
Functional Implications
++
Postural control abnormalities
Greater reliance on vision for maintaining postural stability2
Reduced ability to perform activities of daily living involving head or neck movements
Difficulty sleeping
Reduced psychosocial functioning
+++
Possible Contributing Causes
++
Primary CD
Secondary CD
Drugs
Neuroleptics
Dopamine agonists
Anticonvulsants
Antimalarial drugs
Environmental toxins
CNS lesions
Intramedullary lesions of the cervical cord
Focal brain lesions, such as vascular malformation, tumor, or abscess
Demyelinating lesions, such as with multiple sclerosis
Traumatic brain injury to the contralateral basal ganglia or thalamus
Encephalitis
After hemiplegia as a delayed reaction to stroke
Disease or condition
+++
Differential Diagnosis
++
Diagnosis is by clinical examination; no standard laboratory tests are employed to diagnose CD
Determining that there is no evidence for cause of secondary dystonia is essential in diagnosing primary dystonia
In addition to the possible contributing causes listed, the following pathologies must be ruled out to diagnose primary CD:
Cervical disc disease
Spinal abnormalities
Epilepsy
Muscular dystrophy
Thyroiditis
Endocrine disease4
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
Diagnostic Procedures
++
Diagnosis is made by clinical observation
Toronto Western Spasmodic Torticollis Rating Scale
Torticollis Rating Scale of Tsui
CD Impact Profile
+++
FINDINGS AND INTERPRETATION
++
Imaging (X-ray, MRI, CT) to rule out congenital deformities of the cervical spine, ocular anomalies, CNS pathology,5 neoplasm, thyroiditis, and endocrine disease4
++
++
Surgery is not to be considered unless all other options have failed and symptoms have remained stable over 12 months.2
Selective peripheral denervation.
For laterocollis, denervation of ipsilateral posterior cervical paraspinals, splenius capitis, and sternocleidomastoid muscles is performed.
For rotary torticollis, similar to laterocollis with the exception of denervation of the contralateral sternocleidomastoid.
Deep brain stimulation.
Microelectrodes placed within the globus pallidus internus or subthalamic nucleus.
Multiple follow-up visits required to properly program settings for the stimulator.
Procedure is reversible, and microstimulator settings are adjustable.2
++
++
Pain in the neck region
Decreased cervical range of motion
Decreased cervical strength
Difficulty maintaining head in midline
Dystonic posturing
Poor postural alignment
Balance deficits
++
A thorough examination includes, but is not limited to head position, cervical range of motion, postural alignment and control, muscle length and strength throughout the spine and shoulder region, tone, and balance.2
Functional abilities must be addressed, including stress management, energy conservation, adaptive equipment, mobility, splinting.1
Heat
Traction
Massage
Stretching
Conservative strengthening
Aquatic therapy
Joint mobilization
Inhibitory techniques to temporarily reduce spasm or tone1
++
Patient will be able to
Maintain midline cervical posture for 3 minutes to enhance computer-related tasks.
Achieve 60 degrees of active, combined cervical rotation bilaterally to increase safety while operating a vehicle.
Reduce cervical pain to 2/10 or better 90% of the time.
Demonstrate supportive positioning of the cervical spine to decrease frequency of waking during the night.
++
Most often, CD progresses gradually over a period of months to years.
Remissions have been reported, though most are temporary.
Persistent CD can lead to restricted movements, postural deformity, degenerative osteoarthritis of the cervical spine, and spinal radiculopathies.
++
1. +
Fuller
KS, Corboy
JR, Winkler
PA. Degenerative diseases of the central nervous system. In:Goodman
C, Boissonnault
WG, Fuller
KS Pathology: Implications for the Physical Therapist. 3rd ed. Philadelphia, PA: Saunders; 2007.
2. +
Crowner
BE. Cervical dystonia: disease profile and clinical management. Phys Therl. 2007;87(11):1511–l1526.
CrossRef3. +
Martino
D, Luizzi
D, Macerollo
A, Aniello
MS, Livrea
P, Defazio
G. The phenomenology of the geste antagoniste in primary blepharospasm and cervical dystonia. Movement Disorders. 2010;25(4):407–412. doi: 10.1002/mds.23011.
[PubMed: 20108367]
CrossRef 4. +
Goodman
CC, Snyder
TEK. Screening the head, neck, and back. In:Goodman
CC, Snyder
TEK Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis, MO: Saunders; 2007:640.
5. +
Goodman
CC, Glanzman
A, Miedaner
J. Genetic and developmental disorders. In:Goodman
C, Boissonnault
WG, Fuller
KS Pathology: Implications for the Physical Therapist. 3rd ed. Philadelphia, PA: Saunders; 2007.
7. +
Panus
PC, Jobst
EE, Masters
SB, Katzung
B, Tinsley
SL, Trevor
AJ. Skeletal muscle relaxants. In:Panus
PC, Jobst
EE, Masters
SB
et al. Pharmacology for the Physical Therapist. New York, NY: McGraw-Hill; 2009.
http://www.accessphysiotherapy.com/content/6095617. Accessed June 20, 2013.
+++
ADDITIONAL REFERENCES
+
Ostrowski
C, Ronan
L, Sheridan
R, Pearce
V. An osteoporotic fracture mimicking cervical dystonia in idiopathic Parkinson’s disease. Age Ageing. 2013;42(5):658–659.
[PubMed: 23672934]
CrossRef +
Pelosin
E, Avanzino
L, Marchese
R
et al. Kinesio taping reduces pain and modulates sensory function in patients with focal dystonia: a randomized crossover pilot study. Neurorehabil Neural Repair. 2013;27(8):722–731.
[PubMed: 23764884]
CrossRef +
Queiroz
MA, Chien
HF, Sekeff-Sallem
FA, Barbosa
ER. Physical therapy program for cervical dystonia: a study of 20 cases. Funct Neurol. 2012;27(3):187–192.
[PubMed: 23402680]
Arie J. Van Duijn, EdD, MSc, PT, OCS, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERN
++
Pattern 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders1
++
PATIENT PRESENTATION
A 35-year-old man presents with a sudden onset of low back pain (LBP) 5 days ago, following bending over to pick up an item from the floor. The pain is located along the right side of the lumbar spine, sometimes radiating to the buttock region. Muscle guarding is present along the right side of the lumbar spine. Pain and loss of active range of motion is noted with forward bending, left side bending, and right rotation. Passive intervertebral motion (PIVM) testing revealed significant loss of passive mobility in the same directions. Neurologic examination was unremarkable.
++
LBP with primary involvement of the lumbar facet joint
Lower limb symptoms might be present in a nondermatomal pattern as a result of referred pain
Neurologic findings, minimal
Unilateral symptoms
+++
Essentials of Diagnosis
++
Diagnosis made by clinical examination
Use of treatment- (impairment) based classification system is useful to determine evidence-based practice (EBP) treatment plan
Reproduction of symptoms when putting joint in a closed packed position (combination of extension, side-bending toward involved side, rotation away from involved site)
++
++
+++
General Considerations
++
++
++
SIGNS AND SYMPTOMS
Pain in the lumbar or sacral area that can be mechanically reproduced
Possible unilateral or bilateral referred pain, or pain in lower extremities
ROM limited in a capsular pattern: rotation and side-bending limited in opposite direction
Lumbar segmental hypomobility may be present in capsular pattern
May be associated with poor core-muscle strength and postural deviations
+++
Functional Implications
++
Leading cause of occupational disability
May cause decreased ability to perform activities of daily living (ADLs)/instrumental activities of daily living (IADL)
May impact ability to participate in sports and other recreational activities
+++
Possible Contributing Causes
++
Congenital anomalies
Obesity
Occupational factors
Physical condition
Postural changes
Psychosocial and behavioral factors
Smoking
Socioeconomic factors
Tightness of the hip flexors, external rotators, hamstrings
Weakness of the core musculature
+++
Differential Diagnosis
++
Abdominal aortic aneurism
Ankylosing spondylitis
Hip pathology with radiating pain pattern
Malignant spinal tumor or metastasis
Peripheral nerve impairment
Radiculopathy
Referred pain from visceral structures
Systematic autoimmune diseases (rheumatoid arthrtitis [RA], Reiter syndrome, etc.)
Vascular insufficiency
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
Not necessary in most cases; only with persistent symptoms that do not respond to conservative management or presence of red/yellow flags
MRI2
X-ray/Plain-film radiograph (flexion/extension radiograph)3
CT scan3
Electrodiagnostic/nerve conduction testing4
Doppler ultrasound
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
MRI helps to visualize compressed or inflamed nerve root/disc pathology in diagnosis.2
X-ray/Plain-film radiograph helps to assess alignment, fractures, stability (flexion/extension radiograph).3
CT scan to show herniation compressing the spinal canal/nerves, rule out abdominal pathology.3
Electrodiagnostic/nerve conduction testing can help determine a specific impaired nerve function.4
Doppler ultrasound to examine vascular function.
++
REFERRALS/ADMITTANCE
To hospital for imaging
To physician for surgical consult if myelopathy is suspected (see Lumbar Radiculopathy)
To hospital for imaging and medical consult if disease is suspected
To physician if vascular insufficiency is suspected
++
Hypomobile lumbar spine
Weakness of abdominals and other core-stabilizing muscles
Shortening of hamstrings, hip flexors
Postural changes
Inability to walk for prolonged time
Inability to stand for prolonged time
++
Algorithm for examination of the lumbar spine4
Passive physiologic intervertebral mobility testing (PPIVM)5
Passive accessory intervertebral movement (PAIVM)
Lower extremity screening examination
Postural examination
Muscle length testing, including hamstrings, hip flexors, calf muscles
Quadrant test6
Straight leg-raise test7
Slump test7
Lower limb nerve tension test7
Prone instability test
Lower extremity neurological screen (dermatome, myotome, reflexes)
Repeated movement testing
Fear-Avoidance Beliefs Questionnaire (FABQ)
++
Joint manipulation indicated when, with:
Pain lasting <16 days
No radicular symptoms/pain distal to the knee
Fear avoidance beliefs questionaire (FABQ) score <19
Internal rotation of >35 degrees for at least one hip
Hypomobility of a least one level of the lumbar spine
Joint mobilization
Lumbar stabilization exercises to address core stability when
Positive prone instability test
Presence of aberrant motion
Straight leg-raise >91 degrees
Age <41 years
Initiate stabilization exercises after normalizing ROM
Stretching exercises and myofascial mobilization for shortened musculature
Unweighted treadmill walking
Aquatic exercise
Modalities for short-term pain control
Cognitive behavioral therapy
++
++
Patient will be able to
Sit with a neutral lumbar spine posture for greater than 30 minutes with 0/10 pain rating.
Sit at work station and perform computer work for 45 minutes with 0/10 pain rating.
Rotate lumbar spine 25 degrees with 0/10 pain rating in lower extremity to reach into the back seat in the car.
Walk for 30 minutes with 0/10 pain rating to go shopping.
Increase standing tolerance to >30 minutes without pain to fulfill recreational activity requirements.
++
++
1. +
The American Physical Therapy Association. Pattern 4F: Impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_6. Accessed March 18, 2013.
+++
ADDITIONAL REFERENCES
+
Fritz
JM, Cleland
JA, Childs
JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37(6):290–302.
[PubMed: 17612355]
CrossRef +
Liebenson
C. Rehabilitation of the Spine. Baltimore, MD: Lippincott, Williams & Wilkins; 2007.
+
Olsen
KA. Manual Therapy of the Spine. St. Louis, MI: Saunders Elsevier; 2009.
Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYM
++
++
738.4 Acquired spondylolisthesis
756.12 Spondylolisthesis congenital
805.02 Closed fracture of second cervical vertebra
++
M43.10 Spondylolisthesis, site unspecified
Q76.2 Congenital spondylolisthesis
S12.100A Unspecified displaced fracture of second cervical vertebra, initial encounter for closed fracture
S12.101A Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation1
++
PATIENT PRESENTATION
Patient is a 58-year-old woman involved in a motor vehicle accident. Patient had a bilateral C2 pars interarticularis fracture. The surgeon and patient agreed on conservative management. The patient presents 3 months later with decreased range of motion of the cervical spine and muscle spasms. The patient does not have any dizziness or upper or lower extremity symptoms.
++
Anterior (forward) translation of a vertebra
C2 vertebra anterior translated on C3 with a fracture of C2 pedicles
Fracture of the pedicles on the C2 vertebra
Slipping of the vertebra in relationship to the vertebra below
Neurogenic claudication
Fracture widens at the pars
+++
Essentials of Diagnosis
++
Diagnosis made by X-ray
Clinical examination may find step deformity
Dermatome/myotome pattern
Stability of the cervical spine is critical
Spondylolysis: Fracture without displacement
++
++
+++
General Considerations
++
++
After trauma
Suicidal hanging
++
SIGNS AND SYMPTOMS
Cervical, shoulder, arm, and upper-extremity pain and paresthesia, often radiating into lower extremities if central cord involved
Constricted pupil (Horner sign)
Stiffness along the spine
Headaches
Pain in the cervical spine worsens with extension
Diminished sensation, motor control, reflexes in the distribution of involved nerve
Neurogenic claudication
+++
Functional Implications
++
May cause death
Difficulty maintaining standing posture secondary to neck and arm pain
Inability to sleep flat on the back without a pillow
Weakness with lifting
Loss of movement or feeling in the upper extremity
Difficulty with movements (reaching overhead) secondary to pain
Limited sports participation
++
+++
Possible Contributing Causes
++
Forceful extension from hit under the chin (as in sports)
Congenital
Car accident, hit from rear
Hyperextension of the cervical spine
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
MRI helps visualize compressed or inflamed nerve root in diagnosis.2
X-ray/Plain-film radiograph to see vertebral position3
CT to show herniation compressing the spinal canal/nerves.3
Electrodiagnostic/nerve conduction testing can help determine a specific impaired nerve function.4
+++
FINDINGS AND INTERPRETATION
++
++
REFERRALS/ADMITTANCE
To hospital for imaging
To neurosurgeon for surgical consult if myelopathy suspected
To physician for corticosteroid injection
To physician for anti-inflammatory medication
To orthopedist for halo vest traction device, cervical bracing
++
++
Neck Disability Index score
Cervical spine AROM
Sharp–Purser: Atlantoaxial instability
Cervical passive intervertebral motion testing
Subcranial translation instability testing
Passive physiologic intervertebral mobility (PPIVM) testing
Upper-extremity screening examination
Postural examination
Muscle length testing, including the upper trapezius, levator scapulae, pectoral muscles
Upper limb nerve tension test
Deep neck flexor endurance test
Upper-extremity neurologic screen (dermatome, myotome, reflexes)
++
Rest
Bracing
Address pain
Electrical stimulation
Heat/Ice
Address hypertonicity
Address muscle weakness
++
Patient will be able to
Sit with neutral cervical-spine posture for >30 minutes with 0/10 pain rating.
Stand at work station and perform computer work for 45 minutes with 0/10 pain rating.
Rotate cervical spine 75 degrees in order to look over the shoulder while driving with 0/10 pain rating.
++
Fair to good depend on severity of vertebral translation, amount of nerve-root compression, upper/lower-extremity impairments.
Possible death from asphyxiation.
++
+++
ADDITIONAL REFERENCES
+
Prentice
WE, Quillen
WS, Underwood
F. Chapter 8. Principles of electrophysiologic evaluation and testing. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/abstract/8135087#8135091. Accessed March 8, 2013.
+
Wainner
RS, Fritz
JM, Irrgang
JJ
et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52–62. [PMID: 12544957]
[PubMed: 12544957]
CrossRef
Eric Shamus, PhD, DPT, PT, CSCS, Lindsey (Davis) Hornecke, DPT
++
+++
CONDITION/DISORDER SYNONYMS
++
Simple neck pain
Neck sprain/strain
Mechanical neck pain
++
++
+++
PREFERRED PRACTICE PATTERN
++
4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction1
++
PATIENT PRESENTATION
A 38-year-old female dental hygienist presents with complaints of neck pain with insidious onset 3 weeks ago. She reports she has pain while working on her dental patients and the pain gets worse throughout the day. She rates her pain at 8/10 at its worst. Her pain subsides with rest to a 3/10. She reports having approximately three to four headaches per week that typically arise in the middle of her workday. She also notes she is a very active cyclist and competes in many local races throughout the year.
Her primary care physician in order to evaluate and treat refers her for physical therapy. Physical therapy examination revealed decreased range of motion (ROM) in bilateral cervical rotation and cervical lateral flexion. Cervical and thoracic joint mobility was normal. On palpation, muscle tenderness was noted in the upper trapezius, sternocleidomastoid, scalene, and levator scapulae muscles bilaterally. She also has two active trigger points: one in her right upper trapezius and one in her right levator scapulae. Spurling test and upper limb nerve tension tests were negative for the reproduction of symptoms. There are no signs of muscle atrophy. Manual muscle testing revealed strength 4-/5 for bilateral shoulder elevation, 3/5 for scapular retraction, 3/5 for right cervical lateral flexion, 3+/5 for left cervical lateral flexion, and 3/5 for bilateral cervical rotation.
++
Neck pain from unknown cause
No underlying disease or specific disorder
Usually acute
Chronic, persistent, deep aching pains in the muscle, nonarticular in origin
Usually caused by sudden overload, overstretching, repetitive/sustained muscle activities
Pain associated with activities, generally relieved with rest
Can be in localized area affecting any muscle or fascia
++
+++
Essentials of Diagnosis
++
Diagnosis made by clinical examination (generally palpation) with no medical diagnostic tests available
Differentiated from fibromyalgia, as it can occur in a single area; fibromyalgia occurs in multiple locations, has specific tender points
+++
General Considerations
++
Very common, affects most people in their lifetimes.
Latent trigger points are palpable, taut bands not tender to palpation, but may be converted into active trigger point.
++
In the United States, 14.4% of general population suffers from chronic musculoskeletal pain.
21% to 93% of patients reporting regional pain have myofascial pain.2
25% to 54% of asymptomatic individuals have latent trigger points.2
No racial differences in incidence of myofascial pain have been described.
Myofascial pain affects men and women equally.
Likelihood of developing active trigger points increases with age and activity level.
Sedentary individuals more prone to developing active trigger points than individuals who exercise vigorously on a daily basis.
++
+++
Functional Implications
++
+++
Possible Contributing Causes
++
Anxiety
Behavior
Emotional/psychological stress
Improper lifting, poor biomechanics
Improper posture
Inflammatory conditions affecting ligaments, muscles, tendons
Lack of activity, immobility (cast)
Obesity
Overuse
Poor muscular or ligamentous support
Repetitive stress
Traumatic events
+++
Differential Diagnosis
++
Arnold–Chiari malformation
Carpal tunnel syndrome
Complex regional pain syndrome
Degenerative disc disease
Fibromyalgia
Herniated disc
Ligamentous sprain
Muscle strain
Peripheral nerve impairment
Radiculopathy
Rheumatoid arthritis
Shoulder pathology with radiating pain pattern
Spinal tumor
Thoracic outlet syndrome
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
++
++
++
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
Taut, fibrous band felt with palpation of the muscle
Limited ROM may be common finding
Physical examination cluster to rule in cervical radiculopathy
Spurling test
Rotation limited to ipsilateral side
Upper limb nerve tension test
Diminished brachioradialis reflex
++
++
Pain
Limited function due to reduced ROM
Mobility
Ability to self-care diminished
Role at home, school, work, and in community impacted
Ability to participate in recreation, leisure, and sports impacted
++
Cervical spine AROM
Sharp–Purser: Atlantoaxial instability
Cervical passive intervertebral motion testing
Subcranial translation instability testing
Passive physiologic intervertebral mobility (PPIVM) testing
Upper-extremity screening examination
Postural examination
Muscle length testing, including the upper trapezius, levator scapulae, pectoral muscles
Upper limb nerve tension test
Deep neck flexor endurance test
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Upper-extremity neurologic screen (dermatome, myotome, reflexes)
++
Soft-tissue massage and joint oscillations to reduce pain or muscle guarding
Address biomechanical factors: Improper posture, ergonomics, body mechanics during work, and leisure
Spray and stretch technique
Cryotherapy
In acute cases within 24 to 72 hours of injury to alleviate pain, reduce inflammation
Caution must be used; risk of decreasing flexibility or reinjury
Thermotherapy: Hot packs or whirlpool after initial inflammation subsides to increase circulation and relaxation
Hydrotherapy
Ultrasound to minimize scarring, stimulate tissue healing, increase circulation to the area, relax musculature
Electric stimulation
Stimulates healing, decreases inflammation
Transcutaneous electrical nerve stimulation (TENS) for symptomatic relief of pain
Desensitization of the trigger point with manual pressure
Implementation of strength, power, endurance exercises
Progress from active-assistive to active to resistive exercises, then task-specific performance training
Posture education
Massage
Slow, light percussion to increase circulation, flush lactic acid out of the muscle tissues
Effleurage to relax the muscles
Deep tissue when desensitizing trigger points
Joint mobilizations to eliminate bony restrictions
++
Patient will be able to
Sit with neutral cervical and thoracic spine posture for more than 30 minutes with 0/10 pain rating.
Sit at work station and perform computer work for 45 minutes with 0/10 pain rating.
Rotate the cervical spine 70 degrees so as to talk on the telephone with 0/10 pain rating in the neck/arm
Decrease inflammation to enable repetitive movement.
Increase circulation to decrease inflammation and improve healing response.
Educate patient on proper body mechanics, work area ergonomics, relaxation techniques.
++
Very good, though it may take several months to eliminate trigger points.
Pain may recur if biomechanical causes not addressed
++
1. +
The American Physical Therapy Association. Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_4. Accessed June 5, 2013.
+++
ADDITIONAL REFERENCES
+
Goodman
CC, Fuller
KS. Pathology: Implications for the Physical Therapist. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2009.
+
Hooker
DN, Prentice
WE. Basic principles of electricity and electrical stimulating currents. In:Prentice
WE, Quillen
WS, Underwood
F. Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/content/8136367#8136367. Accessed June 5, 2013.
+
Kisner
C, Colby
LA. Therapeutic Exercise: Foundations and Techniques. 5th ed. Philadelphia, PA: F.A. Davis Company; 2007.
+
Malone
DJ, Bishop
KL. Physical Therapy in Acute Care: A Clinician’s Guide. Thorofare, NJ: Slack Inc.; 2006.
+
Martini
FH, Timmons
MJ, Tallitsch
RB. Human Anatomy. 6th ed. San Francisco, CA: Pearson Education, Ltd; 2008.
+
Silva
AG, Cruz
AL. Standing balance in patients with whiplash-associated neck pain and idiopathic neck pain when compared with asymptomatic participants: a systematic review. Physiother Theory Pract. 2013;29(1):1–18.
[PubMed: 22515180]
CrossRef +
Simons
DG, Travell
JG, Simons
LS, Cummings
BD. Travell & Simons’ Myofascial Pain & Dysfunction: The Trigger Point Manual. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999.
+
Wainner
RS, Fritz
JM, Irrgang
JJ
et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52–62.
[PubMed: 12544957]
CrossRef
Eric Shamus, PhD, DPT, PT, CSCS, Arie J. Van Duijn, EdD, MSc, PT, OCS, Kristie Centner, DPT
++
+++
CONDITION/DISORDER SYNONYMS
++
Low back pain
Mechanical low back pain
Lumbar sprain
++
724.2 Lumbago
847.2 Sprain of lumbar
++
+++
PREFERRED PRACTICE PATTERN
++
4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders1
++
PATIENT PRESENTATION
A 15-year-old girl presents with complaints of unilateral pain along the left iliac crest up to the L5 vertebra. The patient states she has just recently joined a gymnastics team and has had this nonradiating pain since her last practice 5 days ago. She vaguely remembers feeling pain in this area of her left low back after landing a spotted back handspring incorrectly. The patient states she is unable to practice or sit for periods of 30 minutes or longer due to pain and a feeling of instability. Upon palpation, the patient complains of point tenderness along the left iliac crest running up to the transverse process of the L5 vertebra. Passive intervertebral motion testing indicates hypermobility at the L5-S1 segment. Manual muscle testing of lumbar extension and trunk flexion are both 3/5. The patient tests negative for the straight leg raise test and X-rays are negative for fractures.
++
Iliolumbar ligament runs from transverse process of the L5 vertebra to the iliac crest.
Strain can be unilateral or bilateral depending on mechanism of injury.
Tenderness along the line of ligament or at attachments.
Pain over the ligament that does not radiate.
Most episodes are self-limiting.
+++
Essentials of Diagnosis
++
Diagnosis made by clinical examination.
Use of treatment- or impairment-based classification system is useful to determine evidence-based treatment plan.
Reproduction of symptoms in specific postures and activities.
Rule out systemic disease (red and yellow flags).
+++
General Considerations
++
Presentation may vary significantly based on anatomical structures and psychosocial factors.
Often difficult to determine pathoanatomical cause of pain.
Poor spinal alignment can cause irritation of the ligament by altering the length–tension ratio.
++
++
SIGNS AND SYMPTOMS
Pain in the lumbar or sacral area that can be mechanically reproduced
Unilateral or bilateral pain along the length of ligament or attachment
Lumbar segmental hypermobility may be present and indicates instability.
Often associated with poor body mechanics, core-muscle weakness, and postural deviations.
++
+++
Functional Implications
++
+++
Possible Contributing Causes
++
Congenital anomalies
Obesity
Occupational factors
Physical condition
Postural changes
Psychosocial and behavioral factors
Smoking
Socioeconomic factors
Tightness of the hip flexors, hip external rotators, and hamstrings
Weakness of the core musculature
+++
Differential Diagnosis
++
Erector spinae muscle strain
Facet joint dysfunction
Herniated disc
Malignant spinal tumor or metastasis
Myofascial pain syndrome
Referred pain from visceral structures
Sacral dysfunction
Spinal misalignment
Spondylitis
Spondylolisthesis
Spondylosis
Systemic autoimmune disease (rheumatoid arthritis, Reiter syndrome)
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
Not necessary in most cases; only with persistent symptoms not responding to conservative management or if red/yellow flags are present.
MRI helpful in diagnosis to visualize structure of the ligament, compressed or inflamed nerve root, or disc pathology.2
X-ray/Plain-film radiograph helps assess alignment, fractures, and stability (flexion/extension radiograph).3
CT to show ligament structure, herniation compressing the spinal canal/nerves, or to rule out abdominal pathology.3
Electrodiagnostic/nerve conduction testing can help determine specific impaired nerve function.4
Doppler ultrasound to examine vascular function.
Diagnostic ultrasound to analyze fiber orientation.
+++
FINDINGS AND INTERPRETATION
++
++
REFERRALS/ADMITTANCE
To hospital for imaging
To physician for surgical consult if myelopathy suspected (see Lumbar Radiculopathy)
To physician for imaging and medical consult if systemic disease suspected
To other specialist if vascular insufficiency suspected
++
++
Decreased lumbar stability
Weakened abdominals and other core-stabilizing muscles
Shortened hamstrings and hip flexors
Postural changes
Inability to walk, stand, sit for prolonged periods of time
++
Passive physiologic intervertebral mobility (PPIVM) testing4
Lower extremity screening examination
Postural examination
Muscle-length testing, including the hamstrings, hip flexors, and calf muscles
Quadrant test
Straight-leg raise test
Slump test
Schober test, see Figure 124-3
Lower limb nerve tension test
Prone instability test
Lower extremity neurologic screen (dermatome, myotome, reflexes)
Repeated movement testing
Fear-Avoidance Beliefs Questionnaire (FABQ)
++
Joint manipulation indicated when, with:
Pain lasting <16 days
No radicular symptoms/pain distal to the knee
Fear avoidance beliefs questionaire (FABQ) score <19
Internal rotation of >35 degrees for at least one hip
Hypomobility of a least one level of the lumbar spine
Specific exercise when pain centralizes with repeated movement/posture into flexion or extension
Lumbar-stabilization exercises to address core stability when
Prone instability test positive
Presence of aberrant motion
Straight-leg raise >91 degrees
Age <41 years
Traction when
Radiculopathy findings present
Positive crossed straight-leg raise
Pain peripheralized with repeated extension
Stretching exercises, myofascial mobilization for shortened musculature
Unweighted treadmill walking
Aquatic exercise
Modalities for short-term pain control
Cognitive behavioral therapy
++
Patient will be able to
Sit with neutral lumbar spine posture for >30 minutes with 0 out of 10 pain rating for computer work and desk activities
Sit at work station and perform computer work for 45 minutes with 0 out of 10 pain rating
Rotate lumbar spine 25 degrees so as to reach into the back seat of a car with 0 out of 10 pain rating in lower extremity
Walk for 30 minutes with 0 out of 10 pain rating so as to go shopping.
Increase standing tolerance to >30 minutes without pain so as to stand at work.
++
Fair to very good, depending on specific impairments.
Chronic low back pain prognosis significantly lowered.
++
++
1. +
The American Physical Therapy Association. Pattern 4F: Impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders. Interactive Guide to Physical Therapist Practice. Alexandria,
VA: The American Physical Therapy Association; 2003.
http://guidetoptpractice.apta.org. Accessed July 6, 2013.
+++
ADDITIONAL REFERENCES
+
Fritz
JM, Cleland
JA, Childs
JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37:290–302.
[PubMed: 17612355]
CrossRef +
Liebenson
C. Rehabilitation of the Spine: A Practitioner’s Manual. 2nd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 2007.
+
Pool-Goudzwaard
A, Hoek van Dijke
G, Mulder
P
et al.. The iliolumbar ligament: its influence on stability of the sacroiliac joint. Clin Biomech (Bristol, Avon). 2003;18(2):99–105.
CrossRef +
Olsen
KA. Manual Physical Therapy of the Spine. St. Louis, MI: Saunders Elsevier; 2009.
Eric Shamus, PhD, DPT, PT, CSCS, Melissa Tabor, DO
++
++
738.4 Acquired spondylolisthesis
756.12 Spondylolisthesis congenital
805.01 Closed fracture of first cervical vertebra
++
M43.10 Spondylolisthesis, site unspecified
Q76.2 Congenital spondylolisthesis
S12.000A Unspecified displaced fracture of first cervical vertebra, initial encounter for closed fracture
S12.001A Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for closed fracture
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation1
++
PATIENT PRESENTATION
Patient is a 36-year-old construction worker who fell off a ladder and had a burst fracture of the atlas. The physician and patient decided to treat the fracture with immobilization with halo traction and halo vest. Patient achieved a union of his fracture. The patient presents with increased tone bilateral upper trapezius and scalenes with decreased range of motion of the cervical spine.
++
Anterior (forward) translation of a vertebra
Fracture of the anterior and posterior arches of the C1 vertebra
Slipping of the vertebra in relationship to the vertebra below
Ataxia
Fracture widens at the pars
Typically a four-part or “burst” fracture
+++
Essentials of Diagnosis
++
Diagnosis made by X-ray, children may require CT scan
Clinical examination may find step deformity
Axial load on top of the head
Reports diving into a shallow pool
+++
General Considerations
++
++
++
++
SIGNS AND SYMPTOMS
Ataxia
Injury to vertebral artery
Cervical, shoulder, arm, and upper-extremity pain; often radiating into lower extremities if central cord involved
Constricted pupil (Horner sign)
Stiffness along spine
Headaches
Pain in the cervical spine worsens with extension
+++
Functional Implications
++
Difficulty maintaining standing postures secondary to neck pain
Difficulty with movements (reaching overhead) secondary to pain
Limited sports participation
Can cause quadriplegia or death
+++
Possible Contributing Causes
++
Forceful extension from hit under the chin (as in sports)
Car accident, hit from rear
Hyperextension of the cervical spine
Diving into a shallow pool
++
+++
Differential Diagnosis
++
Peripheral nerve impairment
Spinal tumor
Peripheral neuropathy
Paraspinal spasms
Degenerative disc disease
Hangman’s fracture
C2 vertebra anterior translated on C3 with fracture of C2 pedicles
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++