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Cervical Spine Dysfunction vs. Peripheral UE Pain

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Page 1: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Cervical Spine Dysfunction vs. Peripheral UE Pain

Page 2: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Objectives

Brief review of cervical spine and thoracic outlet anatomy

Present common signs and symptoms of cervical nerve root compression

Review video demonstration of evaluations on cervical spine and shoulder patients

Present an early management process.

Page 3: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

7 Reasons Why Patients Don’t Get Better

Psychological

Physical

Depression

Myofacial Pain SyndromeCRPS

Rest-reinjury cycle Inappropriate treatment plan

Failure to correct faulty body mechanics Diagnostic Error !

Page 4: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Why this topic???

Extremely high number of nerve root compression cases that mimic upper extremity dysfunction

Stress the importance of early recognition of both to prevent long term problems (i.e. permanent nerve damage and loss of motor function)

Need for an identification system for these types of patients.

Page 5: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Why so difficult to differentiate?

Cervical Disc vs. UE Dysfunction

Page 6: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Dequervain’s/C-spine NRCCan they both cause…

1) Pain in the wrist? 2) Pain in the neck? 3) Nighttime pain? 4) Loss of sensation? 5) Loss of strength? 6) Loss of reflex?

YesNoYesNoYesNo

Page 7: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Cervical disc herniation

Radiculopathy past the elbow

Loss of reflex Loss of strength Dec. sensation + Compression test + Spurling’s Pain laying supine (no

pillow) Inc. strength with traction +Marquis Maneuver

Page 8: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Rotator Cuff Tear/Impingement

Palpable tenderness in the shoulder

Pain with resistance + Neer’s + Hawkin’s Kennedy Weak ER, abd, flex. Reflexes normal Sensation normal

Page 9: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Cord Compression

Page 10: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Causes of nerve root irritation

Acute injury Repetitive strain Degenerative changes Poor postures

Page 11: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Other causes of NRC

Pastor Bud Video

Page 12: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

ClaudicationVascular vs. Neurogenic

Globalized paresthesia UE’s feel “heavy” or

“dead” UE’s feel “cold” No specific

dermatome Overhead activities

are difficult

Radicular pain prox. to distal

+ Compression test + Spurling’s test Relief with traction No skin discoloration Follows specific

dermatome

Page 13: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

TOS

“Heaviness” in the arm

Difficulty with overhead activity

Globalized paresthesia “Cold/dead” feeling Decreased pulse with

Allen maneuver & Roos test

Page 14: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Thoracic Outlet Syndrome

..\..\..\..\Videos\Paul's Travel CME\C-spine\thoracic outlet syndrome Gary M..wmv

Page 15: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Referred pain from the c-spine

Page 16: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

C5 Nerve Root

Page 17: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

C-6 Nerve Root

Page 18: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

C-7 Nerve Root

Page 19: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

C-8 Nerve Root

No reflex to test

Page 20: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Orthopedic Evaluation of the Cervical Spine

Specific history (MOI) Symptoms ROM Posture & Movement

DTR’s Sensation Strength C-spine compression Inhibitive distraction Spurling’s test Vertebral Artery Palpation

Page 21: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Clear the Shoulder

History Clear the c-spine AROM PROM Manual Muscle Test Neer’s Impingement Hawkins – Kennedy Palpation

Page 22: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Neck or Shoulder?

Page 23: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Neck or Shoulder?

Page 24: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Vicky-Neck or Wrist?

..\..\..\..\Videos\Paul's Travel CME\C-spine\Vickie Boucher C-8 nrc.MOV

Page 25: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Management of Mild Nerve Root Compression

NSAID’s Physical Therapy – C-spine muscle

relaxation, inhibitive distraction (traction), postural program

Ergonomic evaluation Periodic re-evaluation

Page 26: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Scenario #2

Severe pain anterior shoulder, med. border of the scapula, and lateral epicondyle.

Loss of sensation middle finger 3/5 strength triceps Unable to lay on back and extend neck

due to pain Diminished triceps reflex

Page 27: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Management of Scenario #2

Timeliness is key!!!! MRI Steroid pack followed by NSAIDS P.T. to take pressure off of nerve root If inhibitive distraction proves successful,

try home traction unit Consult with neurosurgeon on call Possible LESI or surgery

Page 28: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

What are the goals if the patient responds conservatively or

surgically?

Regain motor strength Avoidance activities Ergonomic assessment Restore cardiovascular

endurance Postural program

Page 29: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it

Paul’s Pearls

1) If there is motor weakness, try manual traction and retest strength. If strength improves then it is cervical and there is nerve root compression.

2) If resistance of a muscle is weak and smooth throughout the range and does not vary in intensity it is probably due to neurological compromise.

Page 30: Cervical Spine Dysfunction vs. Peripheral UE Painmeorthopedicseminars.com/wp-content/uploads/2014/03/J-Differenti… · traction and retest strength. If strength improves then it