Acupuncture in manual therapy 3 cervical spine

Acupuncture in manual therapy 3 cervical spine Acupuncture in manual therapy 3 cervical spine Acupuncture in manual therapy 3 cervical spine Acupuncture in manual therapy 3 cervical spine Acupuncture in manual therapy 3 cervical spine Acupuncture in manual therapy 3 cervical spine Acupuncture in manual therapy 3 cervical spine Acupuncture in manual therapy 3 cervical spine

of injury, pathology, and pain, and integrates them with psychological and social issues to manage cer-vical spine dysfunction and pain syndromes ( Jones

et al 2002 ) Rehabilitation of the cervical spine involves pain management, physical therapies, assur-ance, explanation, education, self-help strategies, ergonomics, and most importantly, exercise.

Assessment

Comprehensive history Subjective history taking should attempt to iden-tify the problem and its cause Special questions of individuals with cervical spine injuries may focus on symptoms of headache and dizziness, the mechanism and intensity of trauma, symptoms suggesting cervi-cal artery insufficiency, and interaction with upper limb activity Clinicians must gain enough informa-tion so that they can develop an effective hypothesis that allows them to apply their own knowledge of pathobiology and effectively manage their patient Consideration should be given to potential red flags (e.g serious life-threatening pathology) and yellow flags (e.g psychosocial indicators).

Objective assessment The aim of manual assessment of the cervical spine is

to identify the presence of any organic musculoskele- tal physical impairment related to the patient’s pain

CHAPTER CONTENTS

Introduction 35

Assessment 35

Comprehensive history 35

Objective assessment 35

Cervical artery insufficiency and manipulative therapy 36

Craniocervical ligament instability testing 36

Neurological examination 36

Adverse neural dynamics 36

Observation 36

Active range of movement 37

Manual assessment 37

Motor and sensory assessment 38

Diagnosis 38

Treatment 39

Spinal manual and manipulative therapy 39

Therapeutic exercise program 40

Research background 44

References 52

3

Cervical spine

Neil Tucker

Introduction

The application of the biopsychosocial and

evidence-based models directs the assessment and

manage-ment of cervical spine disorders In physiotherapy,

the biopsychosocial model recognizes the presence

The initial focus should be on the investigation of

any subjective findings, which may indicate cervical

artery insufficiency, craniocervical ligament

insta-bility, or neurological lesion Early detection of the

presence of any of these factors may impose

fur-ther restrictions on examination and treatment Any

potential symptoms must be monitored carefully

throughout the examination.

Cervical artery insufficiency and

manipulative therapy

Research investigating what was previously called

vertebral artery testing now suggests that therapists

should now be aware of and incorporate the entire

cervical blood flow into their diagnostic triage

Currently, there is a move away from the

cardi-nal vertebral artery signs (Thiel & Rix 2005) and

functional pre-screening tests in patients who are

susceptible to a spontaneous dissection event

dur-ing manual or manipulative therapy (Kerry et al

2007) Clinicians should be aware that symptoms

of cervical artery dissection are diverse, and not only

include the classic brainstem signs and symptoms,

but can also include symptoms such as unilateral

head and neck pain ( Sturzenegger 1994 ) The

lat-est Australian Physiotherapy Association guidelines

( APA 2006 ; Magarey et al 2004 ) suggest that history

taking is the best indicator to use when identifying

those patients who may be at risk Key questioning

around atherosclerotic risk factors and repeated or

significant trauma are two areas that may help a

cli-nician in their clinical reasoning ( Mitchell 2002 ).

Craniocervical ligament instability

testing

As with cervical artery testing, craniocervical ligament

instability testing has shown to have poor sensitivity

and specificity ( Cattrysse et al 1997 ) Therefore, a

comprehensive history and a decision made from a

clinician’s index of suspicion should guide the

man-agement of a patient Krakenes et al (2002) estimated

a probable incidence of alar ligament injuries in 39%

of patients with chronic whiplash associated disorder

(WAD) A history of upper cervical pain post trauma,

radiological evidence of craniocervical abnormalities,

congenital craniocervical anomalies, and

degenera-tive conditions, which may be associated with

crani-ocervical instability, can all be indications for further

investigation or testing Symptoms of cervical artery insufficiency, cord signs, and parenthesis of the lips or tongue (compression of the hypoglossal nerve at the ventral ramus of C2) may raise the index of suspicion

of craniocervical instability The classic tests used clinically are the Sharp-Purser test (transverse liga- ment), the tectorial membrane flexion test, and alar ligament stress tests ( Aspinall 1990 ).

Neurological examination Many nerve root injuries go undiagnosed ( Gifford

2001 ) because the nervous system often provokes vague distributions of pain as well as the classic der- matomal distributions A good neurological examina- tion provides key information about the structures involved, the patient’s prognosis, and the efficacy of treatment A comprehensive history, combined with neurological and musculoskeletal examination, has been shown to provide good diagnostic accuracy in patients with cervical radiculopathy ( Wainner et al

2003 ) Detailed neurological examinations have been described in the literature ( Butler 2000 ) Table 3.1 outlines the sensory signature zones ( Butler 2000 ), associated muscle tests, and muscle stretch reflex for the mid- to lower cervical spine.

Adverse neural dynamics

A neural provocation or neurodynamic test is a ence of movements designed to assess the mechan- ics and physiology of that part of the nervous system

sequ-by elongating the length of the nerve ( Coppieters

et al 2002 ) The following tests are useful in the clinical picture of cervical spine dysfunction:

l Passive neck flexion test;

l Brachial plexus provocation test; and

l Slump tests.

Both the slump and upper limb neurodynamic test have shown to heighten responses in subjects with chronic WAD ( Sterling et al 2002 ; Yeung et al 1997 ) Jull (2001) found that there was a 10% increase in the incidence of sensitized neuromeningeal structures using the passive neck flexion test in chronic headache sufferers.

Observation Forward head posture has historically been linked with cervical dysfunction ( Janda 1994 ) Currently,

the literature associating forward head posture and

cervical spine pain is not strong ( Dalton & Coutts

1994 ; Griegel-Morris et al 1992 ; Haughie et al 1995 ;

Johnson 1998 ; Treleaven et al 1994 ; Watson & Trott

1993 ) The importance of any observations must be

put into context on a multifactorial basis Deviations

may be normal variations Postural differences may

reflect structural, muscle, joint, and neural system

sensitivity, be reactive to pain states, or may reflect

psychological factors.

Active range of movement

There is now enough research indicating that

disor-ders of the cervical musculoskeletal system are

char-acterized by a reduction in range of motion (ROM)

( Dall’Alba et al 2001 ; Hall & Robinson 2004 ; Zwart

1997 ) Deficits in ROM appear not to be

patho-logy specific; however, assessment of active ROM

may give an insight about the structures affected

Distribution of pain associated with bilateral

rota-tion, side bend, upper cervical spine flexion, lower

cervical spine flexion, and extension, plus extension

rotation quadrants, should be recorded Active tests

may be progressed by:

l Applying overpressure;

l Changing the velocity or repetition of the

movement; and

l Applying axial compression or distraction.

Techniques for segmental localization can also be

useful; for example, rotation performed in full

flex-ion to assess upper cervical spine rotatflex-ion (C1 to C2)

has been shown to be limited in the majority of

cer-vicogenic headache sufferer ( Hall & Robinson 2004 )

Sustained positioning can also be of benefit, especially

when subtle pain originating from the nervous system

is apparent The key findings of the active movement

examination should be recorded This information should lead the practitioner in the direction for fur- ther physical examination and provide important out- come measures.

Manual assessment Passive, manual assessment can be broken down into:

l Passive accessory intervertebral movements (PAIVMs); and

l Passive physiological intervertebral movements (PPIVMs).

PAIVMs are short lever techniques used ing assessment of the cervical spine and are also beneficial in the treatment of acute conditions or

dur-in elderly patients ( Hing et al 2003 ) PPIVMs use combined movements to access restriction in a joint using a longer lever.

The manual examination provides basic in vivo measures of pain reproduction and the elastic prop- erties of the viscoelastic tissues of the spinal motion segment This information should support or reject the clinician’s hypothesis gleaned from the initial subjective and objective findings A clinician’s abil- ity to detect a symptomatic segment in the cervical spine has been a point of debate, which questions the basis for the manual examination Jull et al (1988) performed the pioneering study comparing manual examination to local segmental blocks in the cervical spine In this study, the experienced manual thera- pist correctly detected all 15 symptomatic segments

in patients with cervical pain However, King et al (2007) reproduced Jull et al’s study using a larger number of subjects and new local segmental blocking techniques The results of this later study showed significantly lower levels of accuracy in the manual

Table 3.1 Neurological examination for the mid- to lower cervical spine

C5 Distal 1/3 of lateral upper arm Shoulder abduction (deltoid, C5–6) Biceps (C5–6)C6 Thumb Elbow flexion (biceps brachii, C5–6) Biceps (C5–6)C7 Middle finger Elbow extension (triceps, C6–8) Triceps (C7–8)C8 5th finger and ulnar aspect of the palm Thumb extension (extensor pollicis longus,

C7–8)

Triceps (C7–8)T1 Proximal 1/3 of medial forearm Finger abduction and adduction (interossei

and lumbrical, C8–T1)

examination There continues to be discussion about

whether the local segmental block is an accurate

diagnostic tool and about other methodological

dif-ferences published in the studies The manual

exam-ination has also been shown to have poor inter-tester

and intra-tester reliability with regard to detecting

stiffness ( Maher & Adams 1994 ).

Motor and sensory assessment

There is now a significant amount of research

dem-onstrating that there are impairments to the motor

system associated with cervical spine dysfunction

that do not spontaneously resolve ( Falla et al 2004 ;

Jull 2000 ; Tjell & Rosenhall 1998 ; Tjell et al 2003 )

This research has shown that there is impairment to

the deep stability muscles of the cervical spine and

shoulder girdle, and in some instances, oculomotor

and global proprioceptive strategies.

Asking the patient to sit up and assume what they

perceive is correct posture may be a useful way for

assessing the patient’s ability to assume a normal

upright position Clinically, if there is an obvious

pos-tural dysfunction, it is useful to alter the apparent

problem and assess whether it affects the patient’s

symptoms Consideration should be given to the

appropriate sitting, standing, or functional positions

Special attention should be given to the interaction

of the shoulder girdle and cervical spine Loss of the

feed-forward postural mechanisms associated with

upper limb movement ( Falla et al 2004 ) and

low-load holding capacity of the deep cervical flexors

and scapulothoracic muscles ( Grant et al 1997 ) have

been associated with chronic cervical spine

dysfunc-tion Assessment of shoulder elevation and simple

workstation tasks can be clinically useful in detecting

dysfunction The two most common postural

dys-functions affecting the upper limb and cervical spine

are a downwardly rotated scapular and a protracted,

elevated scapula ( Janda 1994 ; Sahrmann 2002).

Specific analysis of the deep flexors of the cervical

spine can be done by looking at a patient’s active

cer-vical spine extension and the craniocercer-vical flexion

test (C-CFT) Active cervical spine extension tests a

patient’s ability to eccentrically use the deep flexors

muscles Dysfunction is commonly seen either when

a patient will not allow the head centre of rotation

to pass behind the frontal plane or when they

per-form a compensatory strategy, therefore loading the

osseoligamentous structures of the cervical spine

( Jull et al 2004 ) The recovery from this position is

also useful to show compensatory motor strategies The C-CFT, as described by Jull et al (2004) , uses

a pressure biofeedback unit (Pressure Biofeedback Unit, Chattanooga Group, Hixon, USA) This tool will augment the skills of a clinician in movement and muscle analysis in order to assess the function

of the deep stability muscles of the neck The aim

of the test is twofold: first, to assess the movement pattern by asking the patient to progressively move the needle up in 2 mmHg increments from 20 to

30 mmHg so as to assess the use of superficial neck muscles and the patient’s kinaesthetic sense; and secondly, to look at the holding capacity for the muscles starting at 22 mmHg for 10-second periods This test gives key information in the implementa- tion of a patient’s home exercise programme The postural control system for the body receives impor- tant information from cervical spine afferents The deep muscles of the upper cervical spine have a high number of muscle spindles, which are responsible for the complex interaction between the cervical spine, ocular motor, proprioceptive balance control, and vestibular systems Dizziness and unsteadiness are the next most frequent complaints (after pain)

in subjects with WAD ( Treleaven et al 2003, 2005 ) Tests for balance, proprioception, and eye movement control are described elsewhere in the literature to which readers are referred ( Jull et al 2004 ).

Diagnosis

Making a diagnosis is essential for goal setting and the clinician’s evaluation of treatment The diagnosis should consider the tissue affected; the time frame

of tissues healing, and the apparent pain nisms This will guide a clinician through the appro- priate clinical reasoning and evidence-based pathway for management Assessment is an ongoing, progres- sive task that must accompany the treatment Red flag conditions should be identified and referred on

mecha-to the appropriate health professional immediately Early identification of yellow flags and patients who may benefit from cognitive behavioural therapy (CBT) is essential for the effective management of this patient group Outcomes such as visual analogue score (VAS) for pain, function, and performance can then be used to record the outcomes of treat- ment The Neck Disability Index (NDI) (Vernon & Moi 1992) and the Patient-Specific Functional Scale (PSFS) (Westerway et al 1998) are two other com- monly used outcome measures Common cervical

spine problems seen within a musculoskeletal clinic

include:

l Cervical postural dysfunction;

l Acute wryneck (apophyseal/discogenic);

l Acceleration/deceleration injury (WAD);

l Radiculopathies (discogenic/spondylotic);

l Stingers (brachial plexus trauma); and

l Osteoarthritis.

Treatment

The aims of physiotherapy treatment are:

l To normalize afferent input;

l To restore ROM;

l To regain optimal motor function;

l To regain optimal proprioceptive function; and

l To address any changeable predisposing factors.

A multimodal treatment approach involving

manual therapy and a therapeutic home exercise

programme (including cervical stability and

propri-oceptive training) have been shown to be of benefit

in the treatment of both traumatic and idiopathic

cervical spine pain ( Allison et al 2002 ; Cleland et al

2007a, b ; Jull et al 2002 ).

Modalities such as acupuncture, electrotherapy, and

soft-tissue mobilization are effective adjuncts to

man-ual therapy, and are good for reducing pain, reducing

soft tissue sensitivity, and promoting relaxation.

Spinal manual and manipulative therapy

Although there is ongoing discussion about the safety issues associated with manipulation of the cervi- cal spine, manual and manipulative spinal therapy (DeFabio 1999) continue to be widely used in the treatment of cervical spine dysfunction The exact mobilization and manipulation mechanisms that pro- vide therapeutic benefit are not known Research indi- cates there is a multisystem response from the motor, sensory, and sympathetic nervous systems (Sterling

et al 2000; Vernon et al 1990 ; Wright 1995 ; Wright & Vincenzino 1995 ) Importantly, it also appears that manual therapy may also improve the performance of the therapeutic exercise programme (Sterling 2000) Most theoretical models of manual therapy use man- ual assessment (active ROM, PPIVM, and PAIVM) and apparent pathological state to determine grade and direction of movement For simple mechanical cervical spine pain, the sequence of palpation, mobili- zation, and manipulation of a spinal segment is logical and simple in clinical application The most common clinical dysfunctions usually involve ipsilateral rotation and side bend dysfunctions The graded application of palpation, mobilization, and manipulation to restore a mid-cervical spine dysfunction is shown in Fig 3.1 The techniques are progressed as the patient’s symp- toms allow and the tissue-healing model indicates With more complex pathologies (e.g acute traumas,

Figure 3.1 l (a) palpation of the cervical spine

(a)

nerve root irritation, segmental instabilities and

arthropathies) more care is needed in the selection

of manual therapy techniques and their application

Tables 3.2 and 3.3 suggest some indications,

precau-tions, and contraindications to cervical spine

mobiliza-tion and manipulamobiliza-tion (adapted from Aspinall 1989 ;

Bogduk 1994 ; Gibbons & Tehan 2000; Gross et al

1996 ; Kerry & Taylor 2006 ; McCarthy 2001 ; Magarey

et al 2004 ; Maitland 2000 ; Mitchell 2002 ; Rubinstein

et al 2005 ; Shekelle & Coulter 1997 ; Sran 2007 ).

Therapeutic exercise program

A good therapeutic exercise programme reinforces a clinician’s manual therapy treatment, and addresses the motor control and proprioceptive requirements

of the patient The patient participation is tial; patients must perceive that they get sympto- matic benefit from it Therefore, education and,

essen-if possible, a clear demonstration that the peutic exercise gives them analgesic or mechanical

Table 3.3 Indications, precautions and contraindications to cervical spinal manipulation

Indications l Informed consent gained

l Acute facet dysfunction with limited muscle guarding and only two linked biomechanical directions of movement loss

l Pain with a regular and recognizable biomechanical pattern

l No contraindications to manipulation present

l The patient has progressed through mobilization procedures, but has a plateau in progressPrecautions l Pregnancy and post partum period

l Craniovertebral anomalies

l Congenital absence of the odontoid process

l Spinal deformity caused by old pathology

l Scoliosis

l Kyphosis caused by adolescent osteochondritis

l Congenital generalized hypermobility

l Ehlers Danlos syndrome

l Patients in whom indications for high-velocity thrust techniques are not presentContraindications l Lack of provision of informed consent by patient

l Malignancy: primary or secondary where there is risk of involvement of the tissues of the vertebral column

l Inflammatory and infective arthritis

l Bone disease: osteomyelitis, tuberculosis, Paget’s disease, osteoporosis

l Cranial artery insufficiency; arteriosclerosis; history of vascular disease

Table 3.2 Indications, precautions, and contraindications to cervical mobilization

Indications l Organic musculoskeletal dysfunction of reproducible pattern

Precautions l Severe pain

l Irritable conditions

l Certain involvements of the nerve root:

 Acute nerve root pain

 Signs and symptoms of increasing neuropathy

 Nerve root irritation

l When spinal movements and/or palpation reproduced distal pain

l Any patient’s condition which is worsening

l Dizziness, aggravated by neck rotation

l Physical involvement of the central nervous system

l Spinal cord compression

l Cauda equina lesions

l Neurological disease

l Inflammatory and infective arthritis (e.g rheumatoid arthritis, cervical spine, active phase)

l Ankylosing spondylosis—active phase

l Bone disease (osteoporosis is not contraindicated provided that extreme care is used)

l Recent fractures

(Continued)

benefit is important There is now over 15 years of

research showing the benefit of a therapeutic

exer-cise programme for patients with both idiopathic

and traumatic cervical spine pain ( Allison et al 2002 ;

Beeton & Jull 1994 ; Cleland et al 2005, 2007a, b ;

Jull et al 2002, 2004 ) These programmes usually

incorporate ROM exercises/mobilization techniques,

deep-flexor (cervical stabilization) strength training,

and ergonomic and postural advice.

Cervical spine articular dysfunction, tight

suboc-cipital muscles, or neural hypersensitivity will often

prevent the patient from performing cervical

stabi-lization exercises Therefore, specific mobistabi-lization

of the upper cervical spine and neural structures is

the starting point for treatment and the home

exer-cise programme Lateral glide techniques have been

shown to be of benefit in patients with neural

hyper-sensitivity ( Allison et al 2002 , Cleland et al 2005 ),

and specific mobilization techniques for the upper

cervical spine can be found elsewhere in the

litera-ture ( Hing et al 2003 ) Two useful, patient-directed

upper cervical spine mobilization exercises are

shown in Figs 3.2 and 3.3 Neurodynamic

mobiliza-tion, as described by Butler (2000) , is also useful.

The aims of a cervical stabilization programme

are to provide specific low-load stimulus to the

deep stabilizers of the neck and shoulder girdle

A holding capacity at 28-30 mmHg without patients

using their superficial musculature will improve their

tonic endurance and is a good initial outcome from treatment Application to the postural and functional requirements of the individual is essential Falla et al (2007a, b) found an increase in deep cervical flexor recruitment of the cervical spine with correct ver- sus incorrect sitting postural strategies, and then showed that patients with chronic cervical spine pain improved their ability to hold an upright sitting pos- ture with deep cervical flexor training and a home exercise programme Incorporating graded interaction with the cervical extensors; superficial neck muscu- lature, and shoulder girdle muscles are common pro- gressions to return a patient to functional tasks When

a patient is able to perform isometric holds of their cervical spine flexors and extensors, kinaesthetic train- ing and balance retraining (in some cases of WAD) may start Revel et al (1994) performed a randomized controlled trial and found that the addition of propri- oceptive and kinaesthetic exercises improved cervical spine position sense, pain, and cervical spine disability Depending on the physical findings (e.g cervicogenic dizziness, unsteadiness and balance disturbance), exer- cises involving cervical spine relocation, gaze stability, eye follow, head-and-eye coordination, and balance can be incorporated into cervical stability exercises The addition of these exercises may also improve motor function in those patients who are struggling

to progress beyond the cognitive training phase of the therapeutic exercise programme.

Table 3.3 (Continued)

l Physical involvement of the central nervous system:

 Spinal cord compression

 Cauda equina lesions

 Neurological disease (e.g transverse myelitis)

l Gross foraminal or spinal canal encroachment on X-ray: advanced degenerative disease

l Acute and severe nerve root pain, irritation or compression

l Presence of involvement of more than one nerve root

l Recent major trauma

l Segmental instability: unstable spondylolisthesis, traumatic or degenerative instability Never manipulate through spasm protecting spinal region

l Post-surgical spinal fusion

l Advanced diabetes when tissue vitality may be low

l Drug use: long-term steroids

l Patients on anticoagulant medication or haemophilia

Figure 3.2 l Hang stretch

Figure 3.3 l right-sided upper cervical spine stretch

Research background

The use of acupuncture for the treatment of

cervi-cal spine pain is not universally supported White

system-atic review that equal amounts of data existed to

both support and refute acupuncture as an effective

modality for neck pain The practitioner is hindered

further in making a reasoned choice by the varying

quality of these papers, a point well made by Smith

et al (2000) Despite these initial difficulties, a

grow-ing body of evidence lays claim to the short-term

benefits of acupuncture for neck pain Nabeta and

Kawakita (2002) found clinically significant results in

a study of cervical spine pain and stiffness, albeit that

the benefits were not maintained at the one-month

follow-up These findings were mirrored by Irnich

et al (2001) with the ceiling of their reassessment

being at 3 months White et al (2004) extended the

follow-up period in their more recent investigation;

although acupuncture was found to be statistically

significant at reducing chronic neck pain and

subse-quent analgesia administration, these results failed to

reach a clinically pertinent level Despite these

per-haps modest claims to utilize acupuncture, collections

of authors have stated more robust arguments Trinh

and long-term trials that acupuncture was effective in

reducing chronic neck pain David et al (1998)

sug-gests from their research that acupuncture is perhaps

most appropriate for those with high baseline pain

scores Irnich et al (2002) suggested more specifically

that motion-related pain in the cervical spine was

effectively treated by acupuncture; it was also found

to be superior to a sham procedure and dry needling.

As advancements in medical scanning technology

have been made, a refinement in the physiological

processes instigated by acupuncture has followed

positive emission tomography imaging (PET) to confirm that only the de Qi sensation at LI4 acti- vated the hypothalamus and subsequently pro- duced a significant analgesic affect Using the same imaging method, Alavi et al (1997) and Biella et al (2001) confirmed that acupuncture activated the same areas of the brain responsible for acute and chronic pain Later studies by Newberg et al (2005) found an asymmetry in the thalamus of chronic pain sufferers before needling; this thalamic varia- tion disappeared after one acupuncture treatment This collection of studies suggests that similar central pathways are shared by nociceptive and acu- puncture signals, but that the central nervous system (CNS) responds in an opposite manner to each ( Wang

et al 2008 ) A less well-researched hypothesis for acupuncture is scrutinized by Cho et al (2006) , who propose that via the hypothalamus–pituitary–adrenal axis (HPA), there is not only central descending pain inhibition, but also communication with possible anti-inflammatory and neuroimmunity pathways It

is postulated that acupuncture suppresses the release

of inflammatory cytokines via the autonomic nervous system ( Kavoussi & Evan-Ross 2007 ); this cholinergic suppression is believed to be a crucial component in the analgesic qualities of acupuncture.

The growing weight of favourable evidence for puncture application gives a practitioner confidence, whilst offering a potential quandary about how best

acu-to implement the most effective programme The following case studies used a clinical reasoning model

in point choice for the management of pain and tional presentation, in order to provide best practice

emo-to support the use of acupuncture, within a torial physiotherapeutic management approach.

A 49-year-old man presented with cervical spine pain

radiating into his right shoulder The subject’s injuries had

occurred following an occupational accident one month

earlier whilst he was pushing a stock crate up a slope

The crate had moved awkwardly, hitting him in the right clavicular region The subject was immediately aware of right-sided neck pain and over the following week, this radiated into his right shoulder Two days prior to his

(Continued)