Download Movement System Impairment Syndromes

Movement Impairment Syndromes
Movement System Impairment
Syndromes: Cervical Spine
Shirley Sahrmann, PT, PhD, FAPTA
And Associates
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Movement Impairment Diagnoses
of Cervical Spine
Extension
Rotation
Flexion
Rotation-extension
Rotation-flexion
Treatment directed at
adjacent regions for neck pain
Adjacent regions critical to consider – examination of patient
with neck pain:
1. Alignment of the thoracic spine, scapulothoracic joint.
2. Weight of the upper extremities and their affect on
cervical rom and pain.
Van Dillen LR, et al.. Clin J Pain. 2007
Andrade GT et al. JOSPT. 2008
3. Movements of the upper extremities and how they
affect compensatory movements at the neck
McDonnell,MK, JOSPT. 2005 /
Takasaki H Spine 2009
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• The syndrome is identified by the direction of
the movement that most consistently is
associated with pain.
• Correction of the movement decreases or
eliminates the symptoms.
Dx & Tx Premise
• Deviations in cervical spine alignment and
movement patterns from the normal
standards contribute to microtrauma and
eventually to macrotrauma.
• Deviations are induced by repeated
movements and sustained postures that
alter the participation of muscles and the
support provided by joint structures.
Normal Cervical Spine Alignment
• Inward curve
• Influenced by length
– intrinsic muscles of
cervical spine
– muscles of shoulder
girdle that attach to
cervical spine
• Alignment of the
thoracic spine
Kendall et al 1993
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Alignment
Common Impairments
• Intrinsic neck muscles become weak or long compromise fine control of vertebral motion
• Extrinsic muscles become dominant adding to
compressive, rotational, & shear forces
exerted on the cervical spine
Treatment: Correcting Thoracic Flexion
> improves cervical alignment
Black et al. Spine.96
Neck Flexors
• Intrinsic muscles
• Longus capitis
• Longus colli
Deep Neck Flexors
Impairment
 Evidence - Impairments of
the deep neck flexors
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• Pure sagittal
rotation
Watson DH et al Cephalgia ‘93
Beazell JR Jrnl Man & Manip Th ‘98
Placzek et al Jrnl Man & Manip Th ‘99
Jull et al Cephalgia ’99
Falla D et al, Cl Neurophys’ 06
 Common muscle
impairment in patients
with neck pain
DeRosa & Porterfield
Poor performance of
deep neck flexors
Deep Neck Flexors Impairment
Implications for treatment
• Weakness of the deep neck flexors
results in translation of cervical spine
• Dominance of Sternocleidomastoid and
Anterior, Middle Scalene
Poor performance of
deep neck flexors
• Translation greater than sagittal
rotation
Forward head with increase
upper thoracic flexion
Flexion – lower spine remains
extended
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• May require assisted
strengthening
Requires assistance to
maintain correct position
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Head and Neck Extensors
Intrinsic muscles
semispinalis capitis
semispinalis cervicis
pure sagittal rotation
Head & Neck Rotators/extensors
• Intrinsic muscles
• semispinalis cervicis
• superior oblique
inferior oblique
• rectus capitis
cervicis
Attached to C2
DeRosa & Porterfield
Splenius & Levator Scapulae
DeRosa & Porterfield
Neck Extensors - Extrinsic
• Rotate head
• Upper Trapezius
• Extend neck
• Levator Scapulae
and neck to
same side
– Cervical spinous processes to scapula
– Cervical transverse processes to scapula
DeRosa & Porterfield
Attachment of Cervicoscapular Muscles
• Trapezius - Levator Scapulae
Movements of the Upper Extremities - Cervical
motion induced by shoulder motion
 Shoulder flexion of the upper extremity
can impose excessive motion of
cervical vertebrae
Takasaki H Spine 2009
 Upward rotation of scapula stretches
levator scapulae muscle and cause
rotation of a more flexible cervical
vertebrae.
 Contraction of upper trapezius can
cause rotation of a more flexible
cervical vertebrae – [next slide]
DeRosa & Porterfield
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Kendall, F. Posture and Pain
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Cervical rotation to the right during left shoulder flexion
Upper trapezius rotates head & neck to opposite side
Right shoulder flexion – no
detectable movement of the
cervical spine
Left shoulder flexion –
detectable movement of the
cervical spinous process to the
left
• Indicative of excessive
mobility of cervical vertebrae
Kendall 1993
Upper trapezius attachments to ligamentum nuchae
Kendall 1993
Repeat shoulder motion with out cervical extension >
decrease pain
Movements of the Upper Extremities
Cervical motion induced by shoulder motion
Compensatory cervical extension with shoulder flexion.
Flexion & Lateral Flexion - Anterior
Shear
• Scaleni
– anterior
– middle
– posterior
• thoracic outlet
• depressed rib
• cervical spine
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cage affects
DeRosa & Porterfield
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Cervical lordosis and thoracic kyphosis
short rectus abdominis - depresses chest
Degeneration associated with frequency & range of motion
3 months later
Singer, Kevin
Compressive forces on cervical spine
Abdominals and Spinal Alignment
weight of head
muscle contraction
downward pull of shoulders/short scaleni
DeRosa & Porterfield
DeRosa & Porterfield
Forward Head Posture
Translation
Increasing thoracic curve increases cervical lordosis
Good alignment
Effect of slumping
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Compression
on facet joints
microtrauma to
articular cartilage
Mechanical Neck Pain
Porterfield & DeRosa
Kendall 1993
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Extension of head & hyperextension of cervical spine
Flexion of cervical spine
Kendall 1993
Kendall 1993
Faulty correction of forward head
lack of correction of kyphosis
Compensatory Hypermobility
Kendall 1993
Cervical Lordosis with thoracic kyphosis
Singer, Kevin
Upper Cervical Range of Motion
Kendall 1993
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Lower Cervical Range of Motion
Orientation of Facet Joints
• upper cervical
– horizontal motion
• lower cervical
– superior motion
Porterfield & DeRosa
Vertebral Motion During Flexionextension
• Flexion - anterior translation 1.9 mm
• Extension - posterior translation 1.6 mm
– retrolisthesis (narrows canal)
Porterfield & DeRosa
Cervical Motion Restricted by Shoulder
Girdle Muscles
• Restricted rotation range of motion
• Passive elevation of shoulder girdle increases
the rotation range of motion
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Activities That Contribute
• Holding telephone with shoulder
• Sitting with head turned watching TV
• Sleeping prone with arm overhead and head
turned to opposite side
• Sleeping on couch with head resting on arm
rest
• Falling asleep sitting up
• Bifocals and computer screen
Cervical rotation limited by
trapezius and levator scapulae muscles
Maximum rotation
Shoulders passively elevated
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Cervical rotation limited by
upper trapezius & levator scapulae muscles
Maximum rotation
Rotation with shoulders elevated
Cervical Extension Syndrome
• Pain with extension
• alignment: cervical
lordosis
• forward head with
DDD
• muscle changes
– short extensors
– long flexors
Forward Head and Forward Shoulder
Initial rotation
Cervical extension elicited
by stretch of levator scapulae
Neck pain decreased by supporting shoulders &
decreasing cervical lordosis
Initial visit
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Post examination
2 weeks later
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Contributing factors: long trunk, short arms,
large breasts with bras straps adding to downward
pull of trapezius and levator scapulae muscles
Neck pain
Initial visit
2 weeks later
Cervical Surgery twice
still had constant pain
Initial Visit
Two Months later
Poor sitting alignment
Corrected sitting alignment
Neck Pain - Cervical Surgery Twice
Initial Visit
Two Months Later
Neck Pain - Cervical Surgery Twice
Initial Visit
Two Months Later
Case Presentation
Headache & Neck Pain
Shirley Sahrmann, PT, PhD, FAPTA
Washington Unversity School of Medicine
– St. Louis
Program in Physical Therapy
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History
• 48 Year old female, Neonatal nurse
• Onset 25 years ago
• Severity: 5 – 10/10; 1½ years ago in bed for 1
month; headache 4x/week, 3 awful
• All forms of treatment; lots of drugs
• Observations:
– Laxity; very forward head, thoracic kyphosis,
swayed upper back; exaggerated by body
language;
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Physical Examination
Markedly forward head
Thoracic kyphosis
Swayed upper back
Body language that exaggerated the above
Passive elevation of shoulder
– Decreased the pain in her upper trapezius area
– Increased cervical rotation ROM
Physical Exam
• Standing: post quadruped rocking: alignment
improved
• Standing: facing wall: shoulder flexion with
scapular posterior tilt at completion of flexion
• Standing: back to wall: shoulder flexion:
Physical Exam
• Swayback posture: postural related activity in
abdominal muscles
• Swelling in area of insertion of scaleni
• Forward bending: increased thoracic kyphosis
• Shoulder flexion: 180 deg but decreased posterior tilt
of scapulae
• Supine: neck flexors 4/5, shoulder flexion WNL,
limited chest expansion with deep breath
• Pectoralis minor: stiff L>R
• Shoulder medial rotation: scapular anterior tilt
Diagnoses
• Cervical rotation-flexion with compression
– From scaleni (abdominals)
– From upper trapezius, levator scapulae
• Scapular depression
– Take deep breath to expand rib cage
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Progress
• Returned two weeks later, markedly improved
• Posture was notably improved and had
stopped body language habits
• Only 1 severe headache and she knew she
triggered it by lifting heavy object
• Supporting arms stops development of any
early symptoms as does performing exercises.
With arm supports
Without arm
supports
Passive elevation of
rib cage
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Without arm support
With arm support
Passive elevation of rib cage
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Treatment Program
• Stop body language
• Correct alignment: stop sway back
– Decrease abdominal muscle activity
• Improve neck flexor strength
• Improve extensibility of scapular depressors
and abdominal muscles and structures
affecting rib cage
• Decrease thoracic kyphosis
Treatment Program
• Quadruped Rocking with relaxation of thoracic spine;
correct support of head and neck
• Standing facing wall; shoulder flexion with shrug
when shoulders are flexed 90 deg
– Scapular posterior tilt at end of range
• Standing back to wall; shoulder flexion, take deep
breath at completion of flexion
• Support arms when sitting; practice cervical rotation
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