Week 2 Lecture
Lecture 2: Triage and Classification: Serious Pathologies and Neurological
- Describe and apply diagnostic triage for patients with neck pain
o Quebec Task Force on Whiplash Associated Disorders (QTF on WAD)
▪ WAD 1: Neck pain w/o musculoskeletal signs (e.g. no loss of ROM and point tenderness)
▪ WAD 2: Neck pain with MSK signs (loss of ROM and point tenderness)
▪ WAD 3: Neck pain with neurological signs
▪ WAD 4: Neck pain with fracture/dislocation (e.g. car accidents) o Waddell’s Back Pain Revolution
▪ Serious pathology (WAD 4)
▪ Radiculopathy (WAD 3)
▪ Non-specific low back pain (WAD 1 & 2)
- Understand, recognise and appropriately act on red flags for neck pain o Serious pathologies → Red flag signs
o Fracture dislocation of cervical spine → significant trauma; osteoporosis;
other pathological fracture
o Infection → Fever; immunosuppression; intravenous drug use; generally unwell
o Malignancy; Rheumatological disease → constitutional symptoms (fever, unexplained weight loss, past history, generally unwell) smoker; Age 50+
(these red flags are common for both cancer and rheumatological disease) o Cord compression; demyelinating disease → neurological signs and
symptoms, upper motor neuron signs
o Cardiac disease → concurrent chest pain; shortness of breath; grey
complexion (Pallor, or pale skin, and grayish or blue skin are a result of a lack of oxygenated blood)
o Atlantoaxial disruption → rheumatoid arthritis; downs syndrome o Arterial dissection → severe pain; 5Ds and 3Ns
▪ Dizziness
▪ Diplopia (double vision)
▪ Drop attack (sudden spontaneous falls while standing or walking)
▪ Dysarthria (reduced muscular control leading to motor speech disorder)
▪ Dysphagia (impairment of language – receptive or expressive)
▪ Nausea
▪ Numbness
▪ Nystagmus
o Detecting serious pathologies:
▪ Cluster of red flags?
▪ Severity?
▪ History and trajectory?
▪ Responsive to conservative treatment?
▪ Regular pattern of pain? (usually have predictable pain pattern is not red flag)
o Acting on serious pathologies:
▪ Making good definitive decisions
▪ Putting patient safety first
▪ Communicating your concerns to the patient w/o causing unnecessary distress
▪ Communicating your concerns to the patient’s treating doctor or hospital
▪ Making actionable recommendations
▪ Closing the loop (of any suspicious pathology…) (i.e. do the follow up or to close out an area of discussion)
- Recognise signs and symptoms and appropriately act on suspicion of vertebral artery insufficiency and cervical arterial dissection
o Cervical arterial dissection (CAD)
▪ A tear in the artery wall
▪ More commonly affecting the vertebral than internal carotid artery
▪ Rare condition but can have devastating consequences (i.e. stroke)
▪ Early presenting features:
• Acute onset neck pain +/- headache → may mimic a MSK presentation
▪ Risk of CAD → may be increased with…
• Exposure to minor trauma
• Infection
• Genetic factors
• Migraine
• Less likely with cardiovascular risk factors
▪ Look out for these features:
• Younger pts under 55 years
• Acute, sudden onset of unfamiliar headache or neck pain
• Moderate – severe pain (often progressing)
• Spontaneous onset following recent exposure to minor trauma or neck strain e.g. sporting injury, recent neck manipulation, jerky head movements, heavy lifting
• Recent unfamiliar neurological symptoms (check 5Ds, 3Ns;
any recent disturbance to balance, speech, vision; any subtle or transient neurological features; Horner’s syndrome)
• Recent infection (prolonged coughing/vomiting) OR
• Developing neurological symptoms and signs during or after examination or treatment
OR
• If there is anything about the patient’s presentation that makes you concerned e.g. reporting atypical pain, severe pain, pain
like nothing experienced previously; the patient is agitated, looks generally unwell
▪ If suspicions are aroused, the PT may check for…
• Balance disturbances
• Gait disturbances
• Horner’s syndrome
• Relevant cranial nerve deficits o Vertebrobasilar insufficiency (VBI)
▪ Characteristically seen in older pts over 65 years
▪ But can also occur in younger people or as a feature of vertebral artery dissection
▪ Symptoms:
• Dizziness
• 5Ds or 3Ns result from insufficient blood supply to the hindbrain
• The pt may have cardiovascular risk factors, e.g. HTN, elevated cholesterol and smoking
▪ Occurs more commonly in association with longstanding neck pain and stiffness
▪ VBI symptoms commonly related to movement and positions of the neck
▪ Be aware of other common causes of dizziness
▪ Physical examination
• VBI positional tests NOT indicated when the pt has clear symptoms of VBI
• VBI positional tests SHOULD BE USED if the symptoms are unclear + clinician is exploring the possibility of VBI in differentiating the source of any dizziness, light headedness or unsteadiness
• Positional tests
o Sustained rotation in sitting
▪ Sustain for at least 10 secs
▪ Wait 10 secs in neutral b/w sides (latency) o If the history indicates, test other neck or treatment
positions as appropriate o Positive test responses
▪ Dizziness
▪ Nystagmus which does not settle within a few seconds
▪ Pre-syncope
▪ Feeling “unwell”
▪ Any of the 5Ds
▪ Cease testing if symptoms not settling w/i seconds and/or getting worse
▪ Treatment
• Never provoke dizziness or other VBI symptoms in Rx
• Avoid end range neck positions during any manipulative therapy or exercise procedure
- Describe the patho-anatomy and -physiology of cervical radiculopathy and myelopathy
o Radiculopathy (specific; sometimes it requires specific Rx)
▪ The impairment caused by malfunction of a spinal nerve root or nerve roots
▪ In order to conclude radiculopathy is present, two or more of the following criteria should be found, one of which must be major (major criteria in bold)
• Loss or asymmetry of reflexes
• Muscle weakness that is anatomically localised to an appropriate spinal nerve root distribution
• Reproducible impairment of sensation that is anatomically localised to an appropriate spinal nerve root distribution
• Positive nerve root tension
• Muscle wasting – atrophy
• Findings on an imaging study consistent with the clinical signs o Mx of Cervical radiculopathy
▪ Surgical/interventional Mx (surgery or other medical interventions)
• Posterior approach: laminoforaminotomy (remove the lamina and open up the foramen from the back)
• Anterior approach: discectomy (removal of a disc fragment, osteophyte, or even the entire disc; sometimes the spinal segment is fused with a bone graft
o +/- fusion
o +/- instrumented, plate or cage o Disc replacement (artificial disc)
• Surgery is an option for the Rx of single-level degenerative radiculopathy → to produce and maintain favourable long- term (> 4 years) outcomes
• …likely that for most pts with cervical radiculopathy from degenerative disorders → signs and symptoms will be self- limited and will resolve spontaneously over a variable length of time w/o specific treatment
• Potential adverse effects
o Post-surgical complication (infections…SpC injury…death)
o Failed back/neck syndrome (for spinal surgery that doesn’t work)
o False hope of miracle cure (can lead to lowered quality of life…reduced morale…)
▪ Other interventional treatments
• Steroid injection (may have side effect of infection) o Epidural
o Transforaminal
▪ Conservative Mx (where PT really shines..)
• Do nothing (watch and wait)
• Treat as non-specific
o First line care (reassureance, education, advice to remain active)
o Adjunctive treatments
▪ Exercise
▪ Prescribed activity
▪ Manual therapies
▪ Electrotherapies, acupuncture…
• Physical therapy decompression techniques o Manual therapy/exercise
▪ Target nerve compression
▪ Sustained mvt or position to open up the IVF
▪ Mobilisation, contralateral neck rotation and lateral rotation
▪ Spinal traction…
▪ ➔ not much evidence but many experts urges to have a try…
▪ Cervical Radiculopathy Surgical (referral) vs Conservative
• Severity and progression consider: neurological signs first, then pain and disability
• Progression (x axis): improving, stable, slow deterioration, rapid deterioration
• Severity (y axis): mild, moderate, severe, extreme
• Green cells: can treat with conservative method (mild
improving, mild stable, moderate improving) → plan episode of care, duration, number of treatments and goal
• Red cells: need to refer → neurological referral → surgery → post-op care → follow the green box p/w
• Yellow: practice judgement and evaluate the pt circumstances (mild slow deterioration, moderate stable, severe improving, extreme improving) → judgement → if trial conservative Mx then follow green box p/w; if neurosurgical referral then follow red box p/w
o Myelopathy (specific potentially serious or very serious) – Cervical myelopathy
▪ A clinical disease involving loss of fine motor control and coordination, gait dysfunction with long tract signs and imaging evidence of cervical cord compression (→ now focus on spinal canal but not the IVF)
• Pain and numbness in the limbs – diffuse bilateral
• Poor coordination (and gait ataxia…)
• Bladder/bowel dysfunction
▪ Prevalence ~ 1.6 per 100,000
▪ Age 50+
▪ Progressive, early symptoms mild (so hard to Dx…) o Mx recommendations:
▪ Severe → surgical decompression
▪ Moderate → surgical decompression
▪ Mild → surgical decompression or conservative rehab with careful monitoring of neurological signs
- Recognise the signs and symptoms of cervical radiculopathy and myelopathy and assist patient centred decisions about management
o Radiculopathy S/S
▪ Dermatomal sensory reduction or loss
▪ Myotomal weakness
• C5: shoulder abduction
• C6: elbow flexion
• C7: elbow extension
• C8: extensor pollicus longus; flexor digitorum profundus
• T1: palmar interossei
▪ Diminished or absent tendon jerk reflexes
• C5:
• C6: biceps jerk
• C7: triceps jerks
• C8:
• T1:
▪ Muscle atrophy
▪ Nerve tension signs
▪ Space occupying lesion in IVF seen on CT/MRI scan o Cervical myelopathy S/S
▪ Pain and numbness in the limbs – diffuse bilateral
▪ Poor coordination
▪ Bladder/bowel dysfunction
Insights on parts that are important in this week’s topic…
1. Understand the triage of neck pain
2. Able to identify different signs and symptoms for serious pathology and understand the corresponding actions as a PT (how to proceed on the care with the pt)
3. Understand when and how to treat a pt with NRC (can use the severity-progression table as a reference + own decision based on pt presentations) (decide whether to treat the NRC or to refer the pt)
4. Understand the clinical features likely associated with pt with myelopathy